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MISSOURI TUBERCULOSIS ASSOCIATION 



Rural School Health Survey 
MISSOURI 



ELIZABETH MOORE 

Director of School Health Surveys 



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702 Pontiac Building, St. Louis, Mo. 

November 1922 



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MISSOURI TUBERCULOSIS ASSOCIATION 

Officers 1922-23 

President, Hon. A. A. Speer Vice-President at Large, Dr. James Stewart 
Treasurer. Mr. A. O. Wilson Recording Secretary, Mr. E. M. Grossman 
Executive Secretary, Dr. Walter McNab Miller 



Board of Directors 1922-1923 
Representing Congressional Districts: 



1st Mrs. George A. Still, Kirksville 
2nd Mrs. Walter Brownlee, ;!rookfield 
3rd (Vacant) 

4th Mrs. R. A. Brown, St. Joseph 
5th Mr. Walter C. Root, Kansas City 
6th Prof. W. E. Morrow, Warrensburg 
7th Dr. A. J. Campbell, Sedalia 
Sth Dr. M. P. Ravenel, Columbia 



9th Supt. B. H. Jolly, St. Charles 
10th Dr. W. McN. Miller, St. Louis 
11th Mr. E. M. Grossman, St. Louis 
12th Dr. James Stewart, St. Louis 
13th Mrs. O. W. Bleeck, Farmington 
14th (Vacant) 

15th Dr. C. T. Dusenbury, Monett 
16th Supt. Robt. W. Crow, Salem 



Representing Senatorial Districts: 

1st Mr. Bert Cooper, Maryville 18th 

2nd Supt. J. W. Thalman, St. Joseph 19th 

3rd Judge W. K. James, St. Joseph 20th 

4th Miss Elizabeth Brainerd, Trenton 21st 

Sth Mr. George Melcher, Kansas City 22nd 

6th Supt. C. C. Carlstead, Keytesville 23rd 

7th Mr. F. W. LeClere, Kansas City 24th 

8th Supt. Price L. Collier, Richmond 25th 

9th Dr. A. G. Hildreth, Macon 26th 

10th Mr. Thomas J. Walker. Columbia 27th 

11th Mr. W. W. Fry, Jr., Mexico 28th 

12th (Vacant) 29th 

'3th Supt. L. M. McCartney, Hannibal 30th 

14th Supt. Chas. R. Mi'burn, Ca'ifornia 31st 

15th Miss Marv W. Fisher, Marshall 32nd 

16th Supt. A. C. Moreland, Butler 33-d 

17th Mr. B. M. Little, Lexington 34th 



Supt. D. W. Clayton, Aurora 
Dr. W. J. Rabenau, Fordland 
Mrs. Wm. Ullman, Springfield 
Mr. Allan Hinchey, Cape Girardeau 
Mr. Wm. R. Haight, Brandsville 
Dr. J. R. Pinion, Caruthersville 
Mr. H. A. Buehler, Rolla 
Hon. Clark Brown, Union 
Dr. R. E. Donnell, DeSoto 
Hon. A. A. Speer, Jefferson City 
Mr. John H. Capelli, Joplin 
Mrs. Philip N. Moore, St. Louis 
Dr. J. F. Bredeck, St. Louis 
Dr. M. A. Bliss, St. Louis 
Dr. Borden S. Veeder, St. Louis 
Mrs. Ernst Jonas, St. Louis 
Dr. George Dock, St. Louis 



Representing Local Organizations: 

Kansas City Tuberculosis Society. Mr. 

Buchanan County Tuberculosis Society Col. 

Columbia Charity Organization Society... Mrs. 

Pettis Countv Anti-Tuberculosis Association..... 
Cooper Co. Health and Educational Association . .Mrs. 

Johnson County Tuberculosis Association Prof. 

Lafayette County Tuberculosis Association Miss 

Greene County Health Association Mr. 

Cole Countv Tuberculosis Committee Mr. 

St. Louis Tub"rculosis Society ....._ Mr. 

Cass County Tubercu'osis Association Mr. 

Jasper County Anti-Tubereulosis Society Mr. 



R. E. Parsons, Kansas City- 
Jos. A. Corby, St. Joseph 
W. E. Harshe, Columbia 
(Vacant) 

Felix Victor, Boonville 
E. B. Wood, Warrensburg 
Mary Marquis, Lexington 
M. D. Lightfoot, Springfield 
A. H. Sieve, Jefferson City 
A. W. Tones, Tr., St. Louis . 
W. E. Smith, Belton 
Frank L. Gass. Cartervilli 



Executive Staff 

Executive Secretary W. McN. Miller, B. Sc, M. D. 

Office Secretary - - — Etta F. Philbrook, A. B. 

Director, School Health Surveys Elizabeth Moore. A. B. 

Director, Modern Health Crusade Helen Guthrie Miller 

Field Representative _ Gladys Roberts, B. S. 



\H 






* CONTENTS 

Page 

Introduction _ j — _ _ _ 1-2 

Purpose v , 1 

Field , - 1 

Scope and method _ _ _ _ — 1 

Physical examination H _ 3-9 

Grade school pupils _ - _ 3-8 

Weight —* 3 

Teeth .. - - 4 

Tonsils and adenoids.- ■. - - * — 5 

Eyesight _ — - - 6 

Hearing — +. 7 

Cervical lymph glands - — 7 

Miscellaneous defects , __ 7 

High school pupils t - - - 8-9 

Weight + ,. _ _ 8 

Teeth 8 

Tonsils and adenoids- - 9 

Eyesight _ _ •• 9 

Home sanitation _ ^ - 10-12 

Home congestion ► _ ^ 10 

Water Supply _ * 10 

Toilet facilities ,. - — — H 

Screening — _ — , - 12 

Correlation with physical condition _ _ , - 12 

Personal hygiene 13-16 

Sleep ._ _____ - 13-15 

B edroom ventilation _ _ - — 1 3 

Crowding in bedroom _ _ * — - 13 

Hours of sleep _ h __ _ 14 

Cleanliness _ _ j _ 15-16 

Bathing _... _ 15 

Eating with clean hands __ , _ 1 5 

Cleaning teeth_ _ „ 16 

Diet + _ - ~~ 17-27 

Diet grades ._ _ __ v .. _ _ _ 17 

Use of milk >__ _ _ _ _ 19 

Coffee drinking _ ,. 21 

Excessive meat, eating __ _ t 21 

Biscuits _ r _ 22 

Pancakes _ _+ _ _ 23 

Pie , _ 23 

Excessive sweets „ _ _. _ 23 

Cereal _ _ , 24 

Eggs , 24 

Fruit and vegetables __ ► * 24 

Regularity in eating _ , 26 

Summary _ _ 27 

Conclusion: What to do about it_ , 28-33 

Remedial measures _ _ _ 28-30 

Physical examinations _ _ 28 

Follow-up work „ _ _ 28 

Children's clinics ,. __ 29 

Preventive measures > _ : _ 30-33 

Home sanitation ..._ , _ 31 

Personal hygiene _ * 31 

Diet , _ _ _ 31 

School lunches _ _ _ __ _ _.. „ 32 

Summary of recommendations , 33 

Tables 34-46 



Rural School Health Survey 

OF THE 

MISSOURI TUBERCULOSIS ASSOCIATION 

By Elizabeth Moore 

INTRODUCTION. 

PURPOSE. — This survey is a study of the health of rural school children 
in Missouri, based upon (a) their physical condition, as shown by a school 
physical examination, and (b) their health habits and environment, as 
learned through home visits and talks with parents. 

It was undertaken as part of the school health campaign of the Tubercu- 
losis Association, with the immediate object of interesting the community 
in providing health supervision for country children, and the ultimate object 
of preventing the development of future cases of tuberculosis through build- 
ing up better general health in the young people of the State. 

The survey was confined to rural children because the Association felt 
that they had been receiving less than their fair share of attention along 
public health lines. 

FIELD. — The survey was carried on in six counties in different parts of 
the State: to-wit, Greene, Johnson, Nodaway, Harrison, Livingston and Mis- 
sissippi. Mississippi County is situated in the Mississippi River bottom in 
the southeastern part of the State; Greene County, on the Ozark Plateau, in 
the southwest; Johnson County, in the Missouri River valley, south of that 
river, but in many respects resembling the northern rather than the south- 
ern part of the State; Nodaway, Harrison and Livingston Counties, in the 
northwest, fairly representing the whole clay-soil upland territory north of 
the Missouri River. The only important section not represented is the hill 
country of the Ozarks; Greene County is much more prosperous and more 
closely in touch with the rest of the world than is most of the Ozark district. 
All six counties have, in the main, distinctly fertile soil; in all except Mis- 
sissippi County, the majority of the country people are prosperous and able 
to live with reasonable comfort. 

Greene County is the only one of the list which includes any city as 
large as 10,000 population. The country population is predominantly Ameri- 
can, usually of native ancestry for* several generations. There were some 
colored families in the districts visited, but even in Mississippi County these 
were comparatively few. 

SCOPE AND METHOD. — Because of limitations of time and funds, the 
survey was made only in a sample of the rural and village schools of 
each county. These schools were selected after consultation with the county 

1 



superintendent of schools, and usually on application from the teacher. The 
list comprised forty-eight rural schools (i. e., in the open country) and 
eleven village schools, of which nine included a high-school department. 

With one exception (812 population) all of these villages were under 
500 population; in other words, this survey was made in no town having 
as many as 1,000 inhabitants. 

In the six counties 2.298 pupils were examined — 1,934 grade pupils and 
364 in the high schools. Seven-tenths (1,351) of the 1,924 white grade-school 
pupils with whom the survey deals, lived in the open country; and three- 
tenths (573) in villages (hereafter referred to respectively as "rural" and 
"town" children). 

With the exception of ten in one town, all the children examined were 
white. It seemed best to confine the study to one race, since it would have 
been impossible to cover both in any adequate manner. All following figures 
and tabulations refer to white children only. 

It was, of course, necessary to make the survey during the rural school 
term. Since country roads in Missouri are practically impassable during 
part of that period, the survey was carried on during parts of three years: 
1919, 1920 and 1921. 

The physical examinations were made in co-operation with local physi- 
cians and in some cases with local dentists. The Missouri Tuberculosis 
Association furnished one or at times two social service workers who 
arranged for the examinations, assisted the physicians with routine work, 
and kept the records. In every county where there was an active medical 
association, its officers were most helpful in securing medical examiners. 
The physicians' and dentists' services were given free of 'charge, as a contri- 
bution to the campaign. 

The examination consisted of weighing and measuring the pupils and 
of tests of vision and hearing, done by the survey workers; of examination 
of the teeth, made by dentists or by the survey workers; and of a physi- 
cian's examination of nose and throat, heart and lungs, with notation of 
other defects which might be observed in a school-room examination. 

Following the school examination, the survey workers visited the home 
of each grade-school pupil (so far as possible) to talk over with the parents 
the results of the examination, explaining the advantage of corrective 
measures where necessary, and to secure information for the home records. 

Such records were secured for 1,499 grade pupils; this number includes 
practically all those examined in four of the six counties. In one county 
(Harrison) bad roads made it impossible to visit any homes outside the 
villages; in another (Livingston) lack of time and workers made it neces- 
sary to omit the home visits in two large school districts and part of a third. 



PHYSICAL EXAMINATION. 
I. Grade School Pupils. 

These physical examinations of rural school children in Missouri have 
confirmed those made in other parts of the United States in showing that 
the common physical defects of school children — malnutrition, decayed teeth, 
defective tonsils, enlarged adenoids, poor eyesight — are prevalent among 
country as well as city children. Different methods of classification make 
direct comparison difficult; but there is no question about the fact, nor 
about the need for preventive and remedial care for children in the open 
country and small towns, who are now receiving less health care than are 
the children of the city slums. 

WEIGHT. — Being as much as 10 per cent below weight i is considered 
by all authorities on the nutrition of children to be a danger sign of mal- 
nutrition, which means being seriously below par in general physical 
condition. Not all children who are even considerably underweight are 
undernourished; but most of them are. 

Malnutrition may have one or more of several causes, the chief of which 
may be classified as: (a) Physical defects, of which by far the most common 
are chronic infections, such as decayed or abscessed teeth or diseased tonsils 
and adenoids; and (b) bad health habits, including over-fatigue, lack of 
sleep, and unwisely chosen or poorly cooked food. (Actual lack of food — 
aside from lack of appetite — is not a frequent cause of malnutrition.) What 
the cause may be in the case of any individual child can be found out only 
by a thorough physical examination and a careful study of the child's 
environment and habits. 

Of importance to the tuberculosis prevention campaign is the fact that 
undernourished children are potentially tuberculous. For this reason, chil- 
dren who are markedly underweight are often called "pretuberculous," and 
efforts are made by tuberculosis associations to place them in special open- 
air schools or in "preventoria" in order to build up their general health and 
ward off possible disease. 

Of all the children weighed in the course of this study (1,897), one-fifth 
(20%) were 10 per cent or more below standard weight, i. e., in the "danger 
signal" group. The smallest proportion (11%) was found in Nodaway 
County and the largest (23%) in Greene and Livingston Counties. Nearly 
one-fourth (24%) of town children were seriously underweight, as compared 
with less than one-fifth (18%) of rural children. In fact, the large propor- 
tion of underweight children in Livingston County was mainly due to its 
town children, among whom 28 'per cent were underweight; in the largest 
village in that county, 40 per cent (two-fifths) of the children were 10 per 
cent or more below standard in weight. In Greene County many children, 
some of whom seemed to be in good health, were not only thinner than the 
average for their age and height, but also taller than the average child of 
the same age. A similar "lankiness" was conspicuous in adults also. It 
seems possible that there may be here in the Ozarks an instance of a taller, 
thinner breed of folk than the average, for whom different standards of 
normal weights would be necessary. On the other hand, the underweight 

l For ag-e and height. Standard tables compiled toy Dr. Thomas J. "Wood were 
used throughout. 



Livingston County children — especially in the village above mentioned — gave 
the impression of being actually in poor physical condition. 

TEETH. — Of almost 1,900 grade pupils whose teeth were examined, 
seven-tenths were found to have unfilled decayed teeth; half of them had 
decay in permanent teeth and half in temporary or "baby" teeth only. This 
is not an unusually large proportion, compared with other studies of school 
children's teeth; for example, the North Carolina State Board of Health 
reports that "examination of approximately 240,000 of these children by 
physicians, nurses and dentists themselves established the fact that about 
80 per cent have defective teeth." However, it brings to our attention the 
fact that the teeth of Missouri country school children are shamefully 
neglected. 

Granted that decay of the permanent teeth is more serious than the 
same defect in temporary teeth, nevertheless an unfilled cavity in any tooth 
is an unwholesome condition, a breeding place for germs; and many of the 
badly decayed temporary teeth seen in children's mouths amply deserve their 
colloquial designation, "rotten." Furthermore, neglected decay in first teeth 
which goes so far that the teeth have to be pulled long before their natural 
time, very commonly leads to crooked second teeth. 

Seven-tenths of those children who still had some of their first set of 
teeth, had visible decay therein. This only feebly expresses the condition of 
many of these children's mouths; one boy, for example, had fifteen decayed 
temporary teeth. On the other hand, only one in twenty-seven had any 
fillings in temporary teeth. Another frequently neglected, unwholesome 
condition is the persistence, sometimes long after the second teeth have 
come, of broken fragments of "baby" teeth and their roots, colloquially 
called "snags." 

When we come to consider the permanent teeth, which should last these 
children the rest of their lives, we find that almost half (47%) of the 
children who had reached their tenth birthday, and fully half (50%) of 
those who had reached their twelfth, had unfilled cavities in their permanent 
teeth. Moreover, only 42 per cent of those children ten years old or over, 
and 35 per cent of those twelve years or over, had normal i (undecayed) 
permanent teeth; 21 per cent and 28 per cent respectively, of the two groups 
had already had dental work (either fillings or extractions) done on their 
permanent teeth; and of those under 10 years, one-fifth already had unfilled 
cavities in their permanent teeth. The moral of these facts is that decay of 
the second teeth begins early; that the permanent teeth must be watched 
constantly from their first appearance, if they are to be kept in serviceable 
condition. 

In this connection it is pertinent to emphasize the fact that the six-year 
molars (recognizable as the sixth in line from the center of the jaw) are 
permanent teeth. This is a fact of which many parents are ignorant; and 
because these teeth, unfortunately, are especially liable to decay, this ignor- 
ance does much harm. Parents who intend to be careful often neglect these 
"No. 6" teeth on the mistaken assumption that they are temporary and will 
soon be replaced. 

At all ages, the town children's permanent teeth were in worse condition 

i Disregarding- irregularity. 



than those of the rural children. While more of the former (by 25% 
against 20%) showed evidence of having visited a dentist, this attention did 
not offset what seems to be a greater liability to decay. In spite of their 
5 per cent excess in dental care, 52 per cent of the 10-years-or-over group 
in the towns had unfilled cavities in second teeth, as compared with 45 per 
cent in the country. 

There are some noteworthy variations among the different counties in 
the matter of dental decay and care (See table, page 35). Mississippi and 
Nodaway Counties showed the highest percentages of children with normal 
permanent teeth, and Greene County the lowest. On the other hand, Greene 
County showed the largest percentage of children who had had dental care, 
and Mississippi County by far the lowest. 

Because of such lack of care, Mississippi County's percentage of children 
with unfilled cavities was practically as high as the average; while Nodaway, 
with more children seeking the dentist, had much the lowest proportion with 
unfilled cavities. 

TONSILS AND ADENOIDS. — There are no recognized standards of what 
may be called pathological (abnormal or unhealthy) adenoids or tonsils. 
Reports on these points are inevitably based on the examiner's individual 
standard, and therefore the findings of different examiners are not strictly 
comparable. Consequently too much stress must not be laid on the figures 
pertaining to these conditions given in this report. 

The co-operating physicians examined 1,831 grade pupils. In this large 
group, nine-twentieths, or nearly half (45%), were reported to have defective 
tonsils, i. e., either enlarged, submerged, or diseased. The percentage ranged 
from 37 per cent in Nodaway County to 54 per cent in Johnson. (At the 
time of the Johnson County survey, an unusual number of children were 
suffering from colds, which possibly influenced the findings as to tonsils.) 

Adenoids, being located in the rear of the nasal passages above the 
soft palate, cannot be seen by the examiner as can the tonsils; and because 
an examination with the fingers or a mirror is out of the question in the 
schoolroom, the physician must base his report upon symptoms, such as 
shape of the nose, mouth-breathing, voice resonance, etc. Different physi- 
cians vary in their standard of judgment regarding adenoids even more 
than regarding tonsils. Some report adenoids probable whenever the tonsils 
are enlarged, while others make an affirmative report only when the adenoid 
is so greatly enlarged that it can be seen hanging down into the throat; 
in one county the examiners reported practically all the mouth-breathers to 
have adenoids, and in another, less than two-thirds. Consequently, figures 
summing up the work of different examiners are ill-defined. In the whole 
survey group of grade pupils, one-third were reported to have adenoids either 
suspected, probable or manifest. 

Adenoids and tonsils are similar glands of what physicians call lymph- 
atic tissue, growing in different parts of the throat. As long as they are 
normal, no harm will come from them; but unfortunately they are often 
abnormal. Then they may do harm in two ways: (1) By becoming so 
over-grown that they block the breathing passages, or (2) by harboring 
chronic "nests" of germs and pus, thereby poisoning the body. It so hap- 
pens that adenoids more commonly misbehave in the former way (hence 
their frequent association with mouth-breathing), and tonsils in the latter 



(hence "diseased" tonsils); but otherwise there is no essential difference. 

In children, if one of these glands is unhealthy, the other is apt to be 
likewise. If the condition is such that it is evidently harming the child, 
either by obstructing his breathing, or by causing frequent head-colds or 
sore-throats, or by pus-poisoning, the removal of the offending gland usually 
will benefit the child. 

Mouth-breathing was observed in two-ninths of the children examined, 
ranging from 19 per cent of Johnson County children to 27 per cent of those 
in Harrison County (the attempt being made not to count children in whom 
the condition was merely temporary, due to a cold). Eighty per cent, on the 
average, of these 409 mouth-breathers were judged by the examiners to have 
adenoids. Some of the remainder were found to have obstructions in the 
front nasal passages (usually enlarged turbinates); but so few physicians 
made nasal examinations that no figures were compiled on this point. 
Among young children, over-grown adenoids are so far the most common 
cause of mouth-breathing that a child who habitually breathes through his 
mouth should always be suspected of having adenoids. 

Whatever the cause may be, breathing through the mouth is an unwhole- 
some condition, a danger signal of something wrong with the nose or 
pharynx, which calls for action. Fortunately it can be remedied if taken 
early enough. If allowed to run on too long, the breathing passages them- 
selves may fail to grow and become permanently deformed. 

Similarly, the evil effects of poisoning from diseased tonsils and adenoids 
may become so serious as to be beyond repair if neglected too long. 

In this connection, the number of children who had had these glands 
removed is of interest; viz., 74, adenoids, and 73, tonsils. This is 11 per 
cent of those reported to have enlarged adenoids, 9 per cent of those re- 
ported to have defective tonsils. The tonsil removal was found to have been 
complete in three-fourths of the cases. 

EYESIGHT. — In order to save the time of the examining physicians 
(who, with one exception, were not eye specialists), routine Snellen vision 
tests were made by the survey workers. Children and teachers were also 
questioned as to symptoms of eyestrain; and the results of the vision tests 
were considered in connection with such indications of strain. It is quite 
possible — as was strikingly illustrated early in the survey — for a child to 
make a good distance vision test, and nevertheless have serious trouble 
with his near vision. 

On this basis, 1,876 children were examined. Forty-five (2%) wore 
glasses. Sixty-one per cent had apparently normal eyesight; 8 per cent 
had questionable eyesight (questionable symptoms, with no definite indica- 
tion of defect) ; and 29 per cent gave evidence of more-or-less defective 
eyesight, uncorrected by glasses. With the exception of Greene County, 
which had only 16 per cent defective, defective vision was remarkably uniform 
in occurrence in the different counties. It was 6 per cent more prevalent 
among town than among rural children. 

If the records are classified simply on the basis of Snellen distance 
vision tests, without regard to other indications of eyestrain, we find that 
nearly one-fifth (19%) of the children made a test below standard (20/30 
or worse) with one or both eyes. This percentage, also, was much lower 
in Greene County than in any of the others. Poor tests were made by 3 



per cent more of town than of rural children. 

The close connection between eyesight and school progress was illus- 
trated by one of the survey children. In spite of being able to read the 
distance test chart correctly, his eyes were so poorly adjusted to close work 
that reading or writing was extremely painful; naturally, he was doing 
very poorly in his lessons. As a result of the survey, his parents were 
persuaded to have him examined by an oculist and to get glasses for him. 
His teacher reported that within two days thereafter, there was a remarkable 
improvement in his work. 

Disregard of proper lighting was much in evidence in the school rooms 
where the survey was carried on. Windows in the front wall were seen 
in a few rooms; but the most common mistake in arrangement was the 
old-fashioned box-car schoolhouse with windows along two opposite sides, 
resulting in crosslights. Blackboards at the front of the room were often 
so poorly lighted as to be difficult for the pupils to see. Some rooms were 
so dark, especially in cloudy weather, that the pupils could hardly see even 
their desk work. A common cause of such poor lighting is window-shades 
which will not roll, so that they cannot be raised on dark days or winter 
afternoons. In the darkest room seen — a room too wide for lighting from 
one side only, with the windows on one side cut off by an addition to the 
building and insufficient window space on the other side — twenty-three of 
the fiftynone pupils had defective vision, and half of those sitting on the 
dark side of the room were troubled in this way. 

HEARING. — Defective hearing was much less common among the chil- 
dren examined than was poor eyesight. Only 5 per cent had hearing def- 
initely below standard (20/25 or worse) and only 2 per cent were seriously 
below par (15/25 or worse). 

CERVICAL LYMPH GLANDS.— Enlarged lymph glands are of impor- 
tance as indications of infection which usually originates elsewhere; those 
of the neck are frequently associated with decayed teeth or diseased tonsils. 
Twenty-one per cent of the children examined had enlarged neck glands; 
10 per cent, slightly enlarged, and 11 per cent, markedly enlarged. 

While there is always a chance that swollen lymph glands may be due 
to tuberculous infection — this is one of the common forms of tuberculosis 
in children— it is impossible to tell whether this is the case with any indi- 
vidual child by a single examination. All other possible sources of infection 
must first be removed, and then the glands watched for several months, 
before such a decision can be made. The fact that 70 per cent of the 
children with enlarged glands had decayed teeth, and 65 per cent had 
defective tonsils, points the moral that such defects should be remedied 
before other sources of infection are inferred to be present. 

MISCELLANEOUS DEFECTS.— The foregoing sections deal with the 
physical defects which were frequently found. Various others were reported 
in a few children, or by individual examiners. 

Only four examiners turned back the children's eyelids to look for 
"granulated lids" or trachoma. One physician in Greene County found 
thirteen cases of "granulated lids" among fifty-one pupils whom he exam- 
ined. Three examiners in Mississippi County discovered fifty-one such 
cases among 152 pupils. (These latter physicians used the terms "granu- 
lated lids" and "trachoma" interchangeably.) 



Ninety-eight pupils in the different counties were reported to have some 
abnormality of the heart.. Forty -one were reported as too rapid (in some 
cases accompanying enlarged thyroid), twenty as irregular, twenty-one as 
showing a murmur, and four as hypertrophied. 

Seventy-eight were found with some impairment of the lungs; forty- 
three of these were "rales," nine reported as "bronchitis," four "dullness," 
four "bronchial breathing." Seventy-seven children were mentioned as 
having a poorly developed or abnormally shaped chest. 



II. High School Pupils. 

A limited number i (364) of high, school pupils were included in the 
physical examinations because of their desire and that of the teachers 
that they might have that privilege. The younger children always were 
given the preference whenever the available medical or dental service was 
limited. The results of these examinations are of interest in comparison 
with those for the grade pupils. 

It must be remembered that high school pupils represent a picked class 
in comparison with grade school pupils. Children who are in really poor 
health are rather unlikely to go on into the high school; and as a general 
rule, the parents of high school pupils are those of the community best able 
and most likely to give their children a good chance physically — to have 
physical defects corrected, for example — as well as mentally. 

In view of this, a marked superiority in physical condition of high 
school pupils might fairly be looked for. But so far as this small group is 
concerned, though some superiority was in evidence, it certainly was 
not great. 

WEIGHT. — Fourteen (14) per cent of the high school pupils were 10 
per cent underweight, as compared with 20 per cent of grade pupils. 

TEETH. — Forty-three (43) per cent had unfilled decayed permanent 
teeth, as compared with 50 per cent of the older' grade pupils (those who 
had passed their twelfth birthday). However, this difference is evidently 
due to the fact that a larger proportion of those high school pupils whose 
teeth needed dental care had received it, rather than to intrinsically better 
teeth. In other words, of the "over-twelve" group of grade pupils, 35 per 
cent still had normal permanent teeth (i. e., teeth which had never 
decayed) ; but only 24 per cent of the high school pupils had such teeth. 
This is about such a deterioration as might be expected from the greater 
age of the high school group. The survey findings for the different groups 
may be conveniently summarized as follows: 

PER CENT OF PUPILS HAVING PERMANENT TEETH AS SPECIFIED. 





Normal 
(no decay) 


Decayed all 
attended to 

11.5 
14.6 
33.0 


Decayed 
partly attd.to 


Decayed 
no work done 


Grade pupils: 

12 years or over 


41.7 
35.2 
23.8 


9.7 
12.9 
23.4 


37.1 
37.3 
19.8 







l In only three counties, Johnson, Harrison, Livingston, were as many as 
fifty high school pupils examined. 



TONSILS AND ADENOIDS. — A somewhat smaller proportion of high 
school pupils than of grade pupils were found to have defective tonsils: 
to-wit, 38 per cent as compared with 45 per cent. 

The difference in regard to adenoids seems to be much more striking — 
i. e., 13 per cent of high school pupils reported affirmatively as against 38 
per cent of the younger children. But the fact that in Johnson County, 
where the nose-and-throat examination of high school pupils was made by a 
specialist, one-third (35%) affirmative reports on adenoids were made, 
throws considerable doubt upon the much lower proportions reported in 
other places for the high school students. However, less than half as large 
a percentage (10%) of the high school group were found to be mouth- 
breathers, as of the younger children (23%). Since these figures were 
made on the same basis of non-medical observation, they are fairly com- 
parable, and corroborate the averages of the physicians' findings, as given 
above. Both agree with the common opinion of physicians that obstructive 
adenoids do have a tendency to shrink as the child grows older, though 
often leaving bad effects behind. 

There were indications that a considerable proportion of mouth-breathing 
among high school pupils was due to enlarged turbinates and other nasal 
obstructions, rather than to adenoids. 

EYESIGHT. — The total proportion of defective eyesight, including pupils 
wearing glasses, was practically the same for the two groups (32% in the 
high schools, 31% in the grades). But owing to the fact that more of the 
high school pupils were wearing glasses, the percentage of uncorrected 
defective vision was reduced to 22 per cent as against 29 per cent in the 
grade schools. 



HOME SANITATION. 

As part of the survey home-records, certain information about sanitary 
conditions of the home was secured, covering crowding, water supply, toilet 
facilities and screening. These data cover 825 homes; 247 in the villages 
and 578 in the open country. No home records in the open country could 
be secured in Harrison County. 

HOME CONGESTION. — On the whole, crowding is not a serious matter 
in the territory of the survey. An average of two or more persons per 
room in the dwelling is a commonly accepted standard of over-crowding. On 
that basis only 11 per cent of the families visited were found to be living 
in congested quarters. Very few cases of extreme crowding — whole families 
living in one room, for example — were found. The greatest amount of 
congestion was in Mississippi and Greene Counties (22% and 17%); in all 
the others, less than one-tenth of the families were living two or more to a 
room; in Nodaway County only three out of eighty. Crowding was a little 
more common, comparatively, in the villages than in the open country, but 
the difference was not marked. (The question of congested sleeping quar- 
ters will be taken up later.) 

WATER SUPPLY.— The kind of drinking water used proved to be 
mainly a question of local possibilities and custom. Wells of one kind or 
another furnished the drinking water for three-fourths (78%) of the 
families visited; cisterns for one-fifth (19%); and springs for comparatively 
few (3% or about 1 in 35). Drilled wells were the commonest source in 
Greene and Harrison Counties; dug wells in Johnson, Nodaway and Living- 
ston Counties; driven wells in Mississippi County. 

Notation was made of any circumstances — e. g., nearness of stables or 
privies, slope of surface toward the well, waste water standing around the 
top of the well — which would create a presumption that contamination of 
drinking water might occur. Such conditions were, naturally, seldom found 
to cast suspicion on drilled wells, which are, as a rule, secure from surface 
contamination except in case waste is allowed to seep down around the 
casing; they comparatively seldom affected cisterns— i. e., practically only 
when the cistern wall was known to leak and admit ground water. On the 
other hand, the defects above mentioned were observed rather often in the 
case of dug and driven wells. 

Carelessness about the location and surroundings of the source of 
drinking water varied greatly in different counties. In the three northern 
counties, such conditions were observed at less than 10 per cent of the 
homes visited; in Greene and Johnson Counties, at 15 per cent and 13 per 
cent respectively; and in Mississippi County, at 29 per cent. 

Mississippi County is so low and level that drainage is extremely poor. 
Until drainage ditches were dug, much of the land was swamp; water 
stands on the surface after any hard rain. Practically all the houses are 
built on piles to keep them out of the wet. Obviously, this state of things, 
combined with the ubiquitous surface privy, gives every opportunity for 
well-contamination, especially as almost every family uses a driven well, 
the casing of which passes through no rock. In the sandy districts, such 
wells are commonly only from 15 to 20 feet deep, and there is ground to 
suspect that any contamination existing on the surface could easily reach 
the intake of the well. 

10 



In the gumbo-clay sections of the county, wells have to be driven much 
deeper — 60 feet or more — and the soil is almost impervious. But, on the 
other hand, unless unusual care is exercised, a mud-puddle of waste water 
forms and stands around the foot of the pump, and such puddles around the 
family's drinking-water pump are often converted into hog-wallows by the 
stock. There seems no good reason why seepage from such a wallow could 
not follow the casing to its opening, even if the soil does "hold water like 
a cup." 

In this connection, it is noteworthy that only in Mississippi County 
did the survey workers come upon patients sick with or just recovering 
from typhoid fever in the families visited. 

Another question about the water supply which is of importance to 
sanitation is its accessibility. If water must be carried or hauled a long 
distance, it is not humanly possible to provide for as many baths, or tooth- 
brushings and hand-washings, for that matter, as if a plentiful supply can 
be drawn in the dooryard, or from a kitchen pump or faucet. 

There are rural districts in the United States in which water must be 
brought long distances to many farm houses. In this respect, rural Mis- 
souri, so far as this survey shows, is fortunate. Practically all of the village 
homes and 97 per cent of the open-country homes had water within 200 
yards; four-fifths (81%) of village homes and five-eighths (62%) of country 
homes had water either inside the house or within 25 feet. 

About one in eleven village homes, and one in twelve country homes 
had water inside the house. In the open country, the percentage varied 
from 2 per cent in Mississippi County to 19 per cent in Nodaway; the 
northern counties far outstripped the southern ones in this respect. Among 
village homes, however, Livingston County fell far behind. There was no 
indication of different economic conditions from those in Harrison County 
(practically neighboring), so that the difference between the two in regard 
to water in the house, 3 per cent as compared with 13 per cent, must have 
been due mainly to difference in standards of comfort. 

Of the forty-nine country families who had water in the house, half 
(24) had running water, and half (25) had only a kitchen pump. Ten of 
the twenty-four (1.7% of the total) had complete plumbing equipment, 
including water-closet and bath with running water and drain. Nine of the 
twenty-three village homes having inside water (3.7% of the total) had 
likewise the complete equipment; these were the only ones having any 
running water. 

TOILET FACILITIES. — As previously indicated, very few of these 
homes had water-closets; to-wit, 2 per cent in the country and 4 per cent 
in the villages. The largest proportions (6 and 7%) were found in rural 
Nodaway County and in the villages visited in Harrison County. No 
example was found of any of the modern types of sanitary privy, built with 
septic tank. Nine-tenths of all the homes visited had one of the two 
ordinary types of privy; either what is known as the "pit" privy, built 
over a hole in the ground, or the "surface" privy, in which excreta are 
deposited on the surface. In the three northern counties, pit privies were 
prevalent, while in the southern counties — especially Greene and Mississippi 
— they were practically unknown. 

Of the two types, it seems probable that the surface privy would be 

11 



the more apt to pollute surface water in its neighborhood. Furthermore, 
it is much oftener built open-in-back, with the result that chickens, rats 
and other scavenging animals may take part in spreading any contagion 
that may occur. Such open-backed privies were found at one-fourth of the 
country homes visited, but seldom in the villages. 

Finally, there was a small proportion of country homes in each county 
— rising to a large proportion in Greene and Mississippi Counties — which 
had no toilet facilities whatever. (This condition also was practically 
absent in the villages.) In Mississippi County 15 per cent, and in Greene 
County 20 per cent of the open-country homes visited had no place except 
the barn or the hen house for the deposit of excreta. Such a state of 
affairs is astonishing in a community as generally progressive as Greene 
County. In one school district visited in that county more than half the 
homes had no toilet. One home, in another district, of apparently good 
standards, had no "out house," although it had a newly built garage. 

SCREENING. — The need for screening the house is well realized in all 
the counties visited, but better heeded north than south of the Missouri 
River. All three of the northern counties showed more than four-fifths 
of the homes completely screened, with Nodaway in the lead, while the 
proportion in the three southern counties varied from three-fifths to two- 
thirds. This is, of course, unfortunate because of the fact that both flies 
and mosquitoes are worse the farther south one goes. Especially in Mis- 
sissippi County, where malaria is still prevalent, mosquito protection would 
be a real health measure; yet here were found the largest number and 
proportion (9%) of homes entirely unscreened. Entire lack of screens was 
rare in the southern counties, and almost unknown in the northern ones. 
Broken screens and incomplete screening, it is true, are of little practical 
service; but at least they indicate an attempt at sanitation and comfort, 
and a possibility of improvement. 

CORRELATION WITH PHYSICAL CONDITION.— An attempt was made 
to find out whether a better or worse health environment in the home would 
be reflected in better or worse physical condition, as indicated by deviatijn 
from standard weight; but in general, no such relationship could be shown. 
In two counties (Harrison and Mississippi) the proportion of 10 per cent 
underweight children was least in the most healthful homes and greatest 
in the most unhealthful; but neither in the other four counties nor in the 
average for the whole six did the figures come out that way. For the open 
country, the children in the distinctly unsanitary homes made the best 
showing as to their weight. 



12 



PERSONAL HYGIENE. 

Information about personal hygiene was obtained for 1,483 children, of 
whom 1,071 lived in the country and 412 in villages. All these were pupils 
in the grade schools. 

SLEEP, (a) Bedroom Ventilation. — The old-fashioned fear of night 
air as such has practically disappeared from rural Missouri, if this survey 
gives a fair sample. Only one child was found who slept with closed win- 
dows throughout the year; the custom in this case was due to a grand- 
mother, with whom the little girl slept, who did not approve of open 
windows. 

On the other hand, the appreciation of fresh, moving air, at all seasons, 
has still far to go before it completely wins the day. Almost half of all the 
children for whom reports were secured were acknowledged to be in the 
habit of sleeping with closed windows in the winter. Some of these, it is 
true, probably got much fresh air, as was often claimed, from loosely-built 
windows, floors and walls. Still, there was a real aversion to open windows 
in cold weather on the part of many parents and children. The belief is 
common in these communities that it is unhealthful to sleep in a room where 
there is a fire; but beyond that, no reason is acknowledged for not following 
the dictates of comfort and keeping as warm as possible. 

Nodaway County leads in appreciation of fresh air as well as at many 
other points. Four-fifths (80%) of Nodaway County survey children slept 
with Windows open the year around. Livingston, Harrison and Johnson 
Counties follow with 68 per cent, 64 per cent, 56 per cent respectively. 
Greene and Mississippi come at the end, with only 42 per cent and 23 
per cent of winter-time open-window sleepers. In Mississippi County it must 
be admitted that there is an unusually large proportion of houses which 
hardly need open windows in order to secure ventilation; but, on the other 
hand, the winter climate there offers the least excuse for shutting up as 
tight as possible. 

(b) Crowding in Bedroom. — An appreciable amount of bedroom crowd- 
ing was reported, to a large extent due to choice rather than to necessity. 
That is to say, parents often keep two or three children in the room with 
them at night, when there is plenty of room for them to sleep elsewhere. 
That this is the case is shown by the fact that over half (55%) the chil- 
dren actually did sleep in the room with two or more other persons, while in 
only about one-fourth (.28%) of the households would this have been neces- 
sary if the members had been evenly distributed among the available bed- 
rooms. Or, going further, 11 per cent of the children slept with four or 
more others in the room, while all but 4 per cent of the homes had bed- 
rooms enough to make such crowding presumably unnecessary. 

In spite of the fact that Nodaway ranked first in absence of general 
house-crowding and Mississippi County ranked last, these two counties stand 
together at the bottom, on the score both of homes with an average of 
at least five persons per bedroom, and of children sleeping with four or 
more others in the room. The explanation of this is probably that in the 
larger dwellings of Nodaway County not so many rooms were equipped and 
used as bedrooms as might well have been, again a matter of choice rather 
than necessity. 

13 



It is notable that 6 per cent of all the survey children slept with four 
or more others in the room with the windows closed in winter. This figure 
was, again, considerably higher in the southern than in the northern coun- 
ties, rising to 13 per cent in Mississippi County. 

The ideal sleeping arrangement would be that each child should have 
a room to himself; this was true of only one-eleventh of the survey children. 
Failing that, a separate bed for each child is desirable, and was provided 
for about one-fifth of the total. Probably no serious objection exists to two 
children sleeping in one bed, and this was the plan followed in the case of 
more than a third (35%) of the children. The common arrangement 
(reported of nearly another third) of having a child sleep with one of his 
parents, or a young child with an adolescent brother or sister, is distinctly 
less advisable. Three or more sharing the same bed creates a condition 
unquestionably unfavorable to quiet, wholesome sleep, yet one-seventh of all 
the survey children slept with two or three bed fellows (often, one of them 
an adult). On this count, Mississippi, Johnson and Nodaway Counties fall 
below the average; Mississippi County was the worst of the three. There 
was, on the whole, somewhat less crowding, both of bedrooms and of beds, 
in village than in rural homes. 

(c) Hours of Sleep. — Probably authorities would agree that eleven hours 
up to eight years of age, ten hours up to twelve years, and nine hours 
during the rest of the growing period, is a fair estimate of the amount of 
sleep needed by school children. 

Using this standard, we find that nearly two-thirds (64%) of the 
youngest group of survey children — those under eight years old — failed to 
get the necessary eleven hours' sleep. On the other hand, nearly two-thirds 
(65%) of the next older group— between eight and twelve years old — met 
the requirement of at least ten hours' sleep; and seven-eighths (87%) of 
those between twelve and sixteen years old had at least nine hours' sleep. 
(It should be remembered that these figures are based on parents' state- 
ments.) The fact that the youngest children are the ones most often getting 
inadequate sleep, agrees with the observation of the interviewers, that, as a 
rule, no attempt was made to fit children's time of going to bed to their 
ages. Customarily, in these families, all children went to bed at the same 
time; in most families, the children stayed up until the grown-ups were 
ready for bed. Any adjustment of sleep to age was customarily made at the 
other end by allowing the younger children, whose help was not needed 
with the work, to sleep later in the morning. That there was some such 
adjustment is shown by the figures; to-wit: on the average the younger 
children slept a little longer than the older ones. There was a decrease in 
hours of sleep of about an hour between the "under eight" and the "fourteen 
to sixteen" group, but this difference was by no means enough to counter- 
balance the greater sleep-needs of the younger children. 

Through all the age-groups, the rural children had slightly shorter hours 
of sleep than town children, and as a result more of them fell below the 
standard. This is in spite of the fact that practically all of the records 
were taken at the time of year— from October through April— when nearly 
all farm families sleep later in the morning than they do during the months 
of rush work. If records of sleep were taken during the summer, the 

14 



country children would undoubtedly make a much poorer showing than they 
do from these winter records. 

On the whole, country families kept earlier hours, both for going to bed 
and for getting up, than village families. This is distinctly to the advantage 
of the rural children, since they sit up with their parents in any event. 

On comparing the various counties, on the basis of the proportion of all 
children under sixteen years old who lived up to our standard of sufficient 
sleep, Mississippi and Greene Counties appear once more with the worst 
records; Harrison County with the best record for town children, and 
Nodaway for country children. 

CLEANLINESS, (a) Bathing. — At least one bath a week in winter and 
two in summer may be taken as a reasonable standard of cleanliness. By 
"bath" is meant an all-over wash, not necessarily in a tub; that can be 
managed in homes without bathtubs, even though it may take some planning 
in winter time. The only really serious difficulty comes when the home is 
badly overcrowded; and, as we have seen, such conditions were rare in the 
territory covered by the survey. 

Taking all counties together, seven-tenths of rural children and eight- 
tenths of village children were reported to get at least a weekly bath through 
the winter. The proportions vary in the different counties, however, from 
three-eighths (37%) in Mississippi County and seven-tenths (69%) in 
Greene County to over eight-tenths in the other four counties. Again we 
find Greene County and especially Mississippi County children falling below 
the average. Livingston County heads the list in regard to winter bathing 
(89% weekly bathers). 

A little more than one-fourth (27%) of all children were reported as 
taking a bath less often than once a week in winter; mostly these children 
bathed every two weeks, or once a month, or irregularly. Only twenty-one 
(1.4%) in the whole survey were acknowledged to take no baths in the 
winter; fifteen of these were in Mississippi County (5.5% for that county). 
On the other hand, sixty-three (4.3%) children were said to take two or 
more baths a week. 

The comparison with our standard for summer (at least two baths a 
week) is even more favorable, "passing" nearly eight-tenths of rural chil- 
dren, and more than eight-tenths of village children. Moreover, many of 
these children exceeded the standard; about one-fifth of the total took daily 
baths in summer, and a great many took as many as one every other day. 
For the summer season, Greene County falls to the bottom of the list (61% 
meeting the standard), with Mississippi County second (72%), and Harrison 
County in the lead (92%). 

(b) Eating With Clean Hands. — This is probably the most important of 
all habits of cleanliness, from the point of view of preventing the spread of 
contagious disease. Health authorities are convinced that contagion is often 
carried from the mouth of a person who has or has had the disease to his 
hands or to some object, then to the hands of another person, and thus to 
his mouth, either directly or by way of his food. 

As a matter of fact, washing the hands before meals is a cardinal point 
of good manners with country folk, no matter whether its importance as a 
health protection is understood or not. In practically every one of these 
Missouri families visited, the children were required to wash their hands 

15 



before coming to the table. So uniform was this report that no figures were 
set down on the point. Naturally, mothers spoke of differences between one 
child and another, as to whether he or she could be trusted to wash without 
a reminder; but there was seldom any doubt about the enforcement of the 
rule. 

When it comes to the question of whether children wash their hands 
before eating at school, that is "a horse of another color." Mothers usually 
expressed doubt about it; and the investigators' observation was that in 
most cases it certainly was not done. Most schools had no means of washing 
except at the pump; a few had a wash basin; in still fewer did the teacher 
establish a routine of hand-washing before the noon meal; in only one 
school were any individual towels seen in use. Under the circumstances — 
i. e., with a common basin and usually either common soap and towel or 
none — it seems questionable whether much would be gained, from the health 
point of view, by urging the children to wash at school. It is difficult to 
see how practical and sanitary means of washing could be provided in the 
absence of running water. 

(c) Cleaning Teeth. — As might perhaps have been anticipated, parents 
reported much more interest in keeping the teeth clean on the part of girls 
than of boys. Almost twice as large a proportion of girls (42%) as of boys 
(23%) cleaned their teeth regularly at least once a day. Likewise, only 
half as large a proportion of girls (11%) as of boys (21%) never cleaned 
their teeth. Among both boys and girls, Greene County children made the 
poorest record for regular teeth cleaning and Nodaway County the best. 
But while Mississippi and Greene County boys were especially remiss to the 
extent of never brushing their teeth (44% in Mississippi County never did 
so), it is surprising to find that among the girls, those of Johnson County 
were most prone to such neglect — followed by Mississippi and Greene. In 
Harrison County all the girls and practically all the boys were reported to 
clean their teeth at least occasionally. 

The record for regular cleaning of teeth is about the same for town 
and country children; but the former did much better than the latter on 
occasional cleaning at least. Only 9 per cent of town boys as compared with 
26 per cent rural, and only 5 per cent town girls as compared with 13 per 
cent rural, neglected their teeth entirely. 



16 



DIET.i 

A child's diet is one of the most important influences in determining 
his physical condition, and at the same time one of the most difficult mat- 
ters about which to secure satisfactory information. In these surveys, the 
attempt was made to secure a statement of what each child had eaten 
during the preceding twenty-four hours, unless for some reason that period 
was not fairly representative of the child's eating habits. It proved possible 
in nearly all families to secure reports of the kinds of food eaten (so long 
as the previous twenty^four hours could be taken), but not of quantities 
except in the case of milk drunk. 

DIET GRADES. — In conference with the food experts of the agricultural 
extension service of the University of Missouri and with the head of the 
Department of Home Economics, the following standards were worked out 
for classifying these diets: 
GOOD: 

No coffee nor tea. 

Pie not more than once a day, and none under 12 years. 

Meat not more than once a day. 

Biscuits not more than once a day. 

No meal exclusively of sweet food. 

Must include: 1 pint milk (milk used in cocoa, milk soups, custards, 
milk gravy, etc., may be included in estimate). 

Cereal. 

Fruit or vegetables at least once a day. 

(Preserves, jam, jelly, etc., not counted as fruit; white potatoes, 
dried beans and peas, not counted as vegetables; canned vege- 
tables and fruit are included.) 
FAIR: 

Those diets which fall between GOOD and POOR. 

Must include at least 1 cup (% pint) of milk if under 12 years. 
POOR: 

Coffee or tea. 

Insufficient milk: No milk at all — any age up to 14 years. 
Less than 1 cup — under 12 years. 

Negligible at 14 years or over, if butter is used, or milk in food. 
(Condensed or evaporated milk counted as none.) 

Meat three times. 

Biscuits three times or to the exclusion of other bread. 

Excessive sweets. 

Pancakes under 14 years. 

Frequent and irregular "piecing." 

Any meal omitted or practically omitted. 
INADEQUATE: 

Clearly insufficient nourishment. 

(The presumption is that any meal omitted will make the diet 
inadequate, unless the contrary appears.) 
On this basis, out of 1,431 children under 16 years old for whom diet 
records were secured, only fifty-six, or one in twenty-five, could be counted 

l The discussion of diets is confined to children under 16 years of age. 

17 



as having a good diet. Yet the standard for a "good" diet cannot be 
regarded as too exacting; in several respects, it falls short of what a child 
ideally should have. Nor does it require anything which is out of the reach 
of country families of limited means. 

Summary of diet grades: 

Good 4% 

Fair 29% 

Poor ' 63% 

Inadequate 4% 

To put the matter in another way, approximately one-third of all chil- 
dren had good or fair diets, while two-thirds had poor or inadequate diets. 
Mississippi County has much the worst diet record — 90 per cent, poor or 
inadequate. Livingston County has the best record (47% good or fair), fol- 
lowed in order by Nodaway, Harrison, Greene, Johnson. 

The question at once arises, what was the matter with all these chil- 
dren's diets? As has been said, 4 per cent of the total (56 in number) were 
judged to provide an insufficient amount of nourishment (not always, by 
any means, because of poverty). Among the 912 diets which were graded 
as "poor" nearly half (48%) fell into that class because of more than one 
of the several specifications given in the standard. On this score, also, 
Mississippi County diets made a very bad showing; not only were nine- 
tenths (89%) of them poor, but of these nine-tenths, two-thirds were poor 
on two or more counts, and three-eighths on at least three counts. 

Taking all counties together, insufficient milk was the commonest reason 
for assigning a poor grade to the village diets; excessive eating of biscuits 
was the commonest cause in the rural homes, followed by excessive meat, 
coffee, and insufficient milk with nearly equal frequency. These four causes 
were dominant in both town and country; in the country, each of them 
overshadowed all other causes combined. However, it was only in the three 
southern counties, especially Mississippi and Greene, that eating biscuits 
was a common failing; in the three northern counties biscuits fell back 
among the comparatively unimportant defects of diet. 

About one-ninth of all the poor diets were in that grade only because 
of including coffee; another one-ninth, only because of insufficient milk; and 
a third one-ninth, only because meat appeared too often. 

It is interesting to find that the younger children (those under 10 years 
old) had a higher proportion of good and fair diets (36%) than their older 
brothers and sisters (only 28% for those between 10 and 14 years old). 
What the reasons for this difference may be, does not clearly appear from 
these records. On some of the points determining a poor diet the older 
children make a poorer showing than the younger ones, while on other 
points the reverse is the case; the items on which the older children make 
a markedly poorer showing are coffee drinking and the excessive eating of 
meat. On the basis of general impressions, the statement might be ventured 
that the older children are left somewhat more than the younger ones to 
their own devices as to what they shall eat: and that children under four- 
teen are too young to exercise good judgment in that matter. 

Poor diets were by no means confined to unsanitary homes; more than 
half the children in the most healthful homes had poor diets. Nevertheless, 

there was some correlation between general health standards and a whole- 

I 
18 



some selection of foods. To be specific: if the homes are classified on the 
basis of general sanitation, we find that nearly half (46%) of the children 
in the highest grade homes had good or fair diets; not quite one-third 
(29%) of those in the medium-grade homes had such diet; and less than 
one-fifth (19%) of those in the distinctly unsanitary homes. 

The children's weights show some relationship to their diet, though not 
very marked. The percentages of seriously (10% or more) underweight 
children in the different diet groups are as follows: 

Good diet 14% 

Fair diet 18% 

Poor diet 19% 

Inadequate diet 45% 

That nearly half the children with inadequate diets should be 10 per 
cent or more underweight is not so surprising as that the other half should 
have escaped that condition. Probably this is due to the fact that with the 
latter group, the deficient diet was only recent or temporary. 

On the other hand, we find that four-fifths of the children who were 
excessively over weight (20% or more), had poor diets. This is not at all 
surprising, since many of the poor diets erred through excess of certain 
types of food — e. g., of sugar and starches — -rather than through deficiency 
of food. Only one child on good diet was found to be excessively overweight. 

USE OF MILK. — One of the most important items in the diet of a 
growing child is a liberal amount of milk. Dietitians and physicians who 
have made a special study of the feeding of children are convinced that 
from two years old up to the end of the growing period, a child ought to 
have at least a pint of milk daily; many hold that the younger children 
ought to have at least a quart. Milk is important for several reasons: as 
one of the chief sources of lime for growing bones and teeth; as one of the 
most wholesome sources of protein for growth and repair of muscles and 
other tissues; and as one of the chief sources of vitamins, the newly dis- 
covered regulating substances necessary to growth and health. One of these 
vitamins, fat-soluble A, is more abundant in the fat of milk — and therefore 
in butter and cream — than in any other common food. (Because heating 
destroys more or less of the vitamins, evaporated milk is of less value to a 
child than is fresh milk; "condensed" skim milk has also lost its valuable 
fats, and contains more sugar than is wholesome as a steady diet.) 

For this reason, a pint of milk was made one of the requirements for 
a good diet. Up to 12 years of age, at least a cup of milk was required for 
even a fair diet; and some milk, up to fourteen years. 

Three-quarters of the village children and four-fifths of the country 
children in the survey had some fresh i milk or cream in the day's diet. 
Approximately half the children (somewhat more in the country and less 
in the villages) had milk to drink; a few additional had cocoa or soup 
made of milk. About one-fifth used only milk or cream as "trimming" on 
cereal or fruit, or in coffee or some other drink; these obviously got con- 
siderably less milk than the former group. Out of the remainder, a few— 
5 per cent in the villages, but only 1 per cent in the country — used con- 
densed or evaporated milk, not to drink, but as flavoring for coffee or cereal, 

i As distinguished from condensed or evaporated milk. 

19 



etc. This leaves 18 per cent of the total who had no milk or practically 
none. The majority of these, however, did have butter, and therefore 
secured one of the valuable elements of milk. A few children got an almost 
negligible amount of milk cooked in such foods as gravy or custard (usually 
gravy only); and finally there remain only 5 per cent (1 in 20) who had 
no milk, cream, nor butter whatsoever. 

To recapitulate — the percentages of country and village children using 
milk in various forms are as follows: 

Country Village 

Milk to drink 56.6 46.7 

Soup or cocoa made of milk 4.4 5.9 

Milk or cream as "trimming" 20.6 22.7 

Total of above... 81.6 75.3 

Condensed or evaporated milk only (with or 

without butter) 1.1 4.8 

Butter only 10.3 12.5 

Milk cooked in food only (no butter) 2.3 2.8 

No milk, cream nor butter 4.7 4.6 

Over nine-tenths of the country children in Nodaway and Livingston 
Counties had some fresh milk or cream; six-tenths of them had milk to 
drink. The smallest proportion of country children getting any fresh milk 
or cream was in Mississippi County (68%). Of town children, the smallest 
proportion drinking milk or having any fresh milk was in Johnson County. 

There was a steady drop in the proportion of children drinking milk, 
from 60 per cent among those under 8 years old, to 48 per cent among the 
14-to-l 6-year-old group. 

In most cases, complete absence of milk and butter from the diet was 
due to an actual lack of milk in the home. (This was true of sixty-one 
children out of sixty-seven. ) And every family but one which used con- 
densed or evaporated milk, did so because they had (and usually could get) 
no fresh milk. Among the children who ate butter but got no milk nor 
cream, about a third belonged to families where there was lack of milk; the 
others apparently might have had at least a little milk if they had wanted 
it. Altogether, only about one-tenth of the records show that a child was 
deprived of milk because there was none or not enough to go around. Nat- 
urally, this percentage was twice as high in the villages as in the country 
(16% as compared with 8%). 

In a great many cases, failure to drink milk, or even to eat milk or 
cream with other food, was acknowledged to be due to the child's dislike of 
milk. In a few cases, it was due to a belief that milk disagreed with the 
particular child. Instances were not infrequently seen where the adults of 
the family drank milk but the children did not. 

In this connection, it is pertinent that nine-tenths of country families 
kept at least one cow (most commonly, from 2 to 4 cows), while only two- 
fifths of village families kept a cow. Yet none of the towns included in the 
survey was large enough to make it really difficult to find space for a cow; 
and in several of them, it was reported to be almost impossible to buy milk. 
Generally, there was no lack of butter for sale in these villages; but in one 

20 



or two towns the use of vegetable butter substitutes was common, mainly as 
a measure of economy. Such vegetable butters do not contain the vitamin 
which makes real butter so valuable. 

The use of separated milk (which is robbed of practically all its fat) 
for family consumption was rare except in Greene and Johnson Counties — 
the only ones having any number of large dairy herds — and was not common 
there. Outside of Mississippi County, more than half (59%) the children 
who drank milk, had whole mink at least part of the time; but in Mis- 
sissippi County, only one in thirteen drank whole milk. Most of the other 
children drank hand-skimmed milk, which is, as a rule, about half-skimmed. 
In Mississippi County, and to a less extent in Greene County, buttermilk 
was a favorite beverage with the children. Buttermilk is unquestionably 
wholesome, but contains only about half as much nourishment as whole 
milk. 

Only among the children who drank milk (with one or two exceptions), 
were any found who could be accepted as meeting the requirements for a 
good diet, i. e., that they should consume at least a pint of milk a day. In 
the country, three-quarters of the children who drank any milk, drank at 
least a pint; in the villages, about five-eighths drank that much. Out of all 
the country children for whom records were secured, two-fifths (42%) drank 
at least a pint of milk during the day; among the village children, three- 
tenths (29%) consumed that amount. 

In the country, the largest proportion drinking a pint of milk was in 
the 8-to-10-years group; in town it was much the largest in the under-8-years 
group. 

For the whole survey, Ave find that 39 per cent of the children consumed 
at least one pint of milk, and therefore met that requirement for a good 
diet. Nearly three-fourths (73%) met the milk requirements for at least 
a fair diet, while one-fourth (27%) fell below even that standard. 

COFFEE DRINKING.— Nearly one-quarter (24%) of the" survey chil- 
dren were reported as drinking coffee; the percentages varied from 34 per 
cent in Mississippi County, and 30 per cent in Greene County, to 18 per cent 
in Nodaway and 16 per cent in Harrison. This is a poor showing, espe- 
cially for the two southern counties. Coffee (and tea also, though to a less 
degree) contains a stimulating drug which should not be given to children 
until they have ' reached their full growth. 

The harm done by coffee is usually the greater, the younger the child. 
It is therefore encouraging to find that the younger children were somewhat 
less subject to this habit than the older ones. By ages, the percentages of 
children drinking coffee are: 

Under 8 years 17.7% 

8 to 10 years 22.6% 

10 to 12 years 24.6% 

12 to 14 years 29.1% 

14 to 16 years 31.4% 

Nevertheless, it is deplorable that one-fifth of the children even under 10 
years old were allowed to have coffee. 

EXCESSIVE MEAT-EATING.— As a rule, both country and village fam- 
ilies in the territory of the survey are in the habit of having meat at every 
meal; no meal is considered complete without it. Through the winter and 

21 



early spring — i. e., the period covered by the survey records — "meat" is 
usually cured pork of some kind: ham, fat bacon, or perhaps sausage. 

As against this custom, authorities on the feeding of children have 
come to the conclusion that children should not have meat more than once 
a day; that if they have plenty of other protein food — e. g., milks and eggs 
— they get along very well without any meat at all. 

The diet records show that more than half (53%) the children ate meat 
more than once a day, and therefore failed to fulfill, in this respect, the 
requirements for a good diet. Furthermore, between one-fourth and one- 
fifth of them (22%) ate meat three or more times a day, and thereby threw 
themselves into the poor diet class. Meat was eaten to excess (3 or more 
times a day) by a larger proportion (one-fourth) of country children than 
of village children (one-sixth). 

Up to 14 years of age, there was a marked increase in excessive meat- 
eating as the children grew older. The percentages eating meat at least 
three times a day are: 

Under 8 years 15.7% 

8 to 10 years 16.9% 

10 to 12 years 25.6% 

12 to 14 years 29.8% 

14 to 16 years 26.0% 

In comparing the different counties, it is interesting to find that the 
counties whose records appear well above the average in avoidance of too 
much meat for the children are Greene and Livingston, where the records 
were taken in the spring. At that time of year, country folks are thoroughly 
tired of salt meat, their winter supply is often exhausted, and meat is 
frequently replaced by eggs in the dietary. Accordingly we find in these 
same two counties a much larger proportion of children eating eggs than 
in the other four. Between the four "winter" counties there is no signifi- 
cant difference as to eating of meat, and it is likely that the better showing 
of the other two counties would disappear if records were taken at the 
same season. 

BISCUITS. — As previously mentioned, biscuits are a staple article of 
diet in the three southern counties, and most especially in Mississippi 
County. In Mississippi County, five-eighths (62%) of survey children, and 
nearly as large a proportion of families visited, used biscuits to the exclu- 
sion of all other kinds of bread; seven-tenths of the children (69%) ate 
biscuits three or four times a day. In Greene County, a quarter (24%) ate 
biscuits at least three times a day, and one-fifth (19%) ate no other bread; 
in Johnson County, one-tenth (10%) of the children ate no other bread, and 
one-ninth ate biscuit three times a day. 

In the three northern counties, from eight- to nine-tenths of the diets 
contained no biscuits at all, while only three children (in Nodaway County) 
had them for three meals. In that part of the State, when hot biscuits 
were served at all, it was usually only once a day, as a special treat. 

The importance of this item lies in the fact that hot biscuits, even if 
skillfully made, are held to be unwholesome for children because biscuit 
dough is apt to form indigestible lumps instead of being readily crumbled in 
chewing, as is stale yeastbread or cornbread. Furthermore, if there is too 
much soda in biscuit, as happens not infrequently, that destroys vitamins. 

22 



Therefore, the food, experts who drew up our diet standards laid down the 
rule that no day's diet containing biscuits more than once could be consid- 
ered satisfactory. 

Accordingly, we find that in the several counties, the following percent- 
ages of diets would be thrown out of the "good" class on the ground of 
biscuits, if for no other reason: 

Mississippi County 86.5% 

Greene County 40.2% 

Johnson County 31.2% 

Nodaway County 8.8% 

Harrison County 0.9% 

Livingston County 0.9% 

PANCAKES. — For similar reasons, and for the additional reasons that 
the batter cannot be thoroughly cooked and that fried food is indigestible 
as a rule, pancakes are regarded as unfit food for children; yet we find about 
one in twenty (5%) of the children, even the youngest, eating them. Rather 
surprisingly, much more than this proportion of town children in Harrison 
and Johnson Counties, and of rural children in Nodaway County (13% — 
12% — 8%) had pancakes in their day's dietary, while in the other groups 
pancakes appeared very seldom. 

PIE. — Of similar nature are the objections to children's eating pie; 
although pastry is not fried, it ordinarily contains enough fat to interfere 
with digestion of the flour. And pie, unlike pancakes, proved to be a com- 
mon vice in all counties. In Greene County, two-fifths (42%) of the chil- 
dren were reported as eating pie in the sample day — one-seventh of them 
(14%) twice during the day. In the other five counties, from one-fifth 
(20%) to one-fourth (28%) of the diets included pie at least once. There 
again, we have an unsuitable article of diet just as frequently permitted 
to the youngest children as to the older ones. 

EXCESSIVE SWEETS. — Comparatively few (only 4%) of the diets, as 
reported, could fairly be charged with being excessively sweet throughout; 
more than two-thirds of these were in Johnson and Mississippi Counties, 
with very few in the other four. But a considerably larger proportion. 
(12%) of children were allowed to eat some one meal made up entirely of 
sweet food. This is a habit which children will fall into readily if not 
watched; and. it . undoubtedly tends to upset the stomach and lessen appe- 
tite. Children should be carefully taught that sweets should come only as 
dessert at the end of a meal, after other food (not sweet) has been eaten. 

An excessive proportion of such all-sweet meals was reported in John- 
son and Mississippi Counties, and likewise in Harrison County. 

The preceding sections, except that on the use of milk, deal with faults 
in diet which may be called "faults of excess," consisting either in allowing 
children to have something which they should not have at all, such as coffee 
or pancakes, or in allowing them to have too much of a food like meat, 
which is all right if eaten in moderation. The other class of mistakes — 
"faults of deficiency" — consists of omitting from the diet certain foods which 
the child ought to have. 

As has been explained, milk is the most' important of these requisites. 
Others are wholesome bread (see under "Biscuits"); and butter, which, with 
the exception of the 5 per cent already spoken of who had neither milk nor 

23 



butter, nearly every child in this survey ate. Still other desirable articles 
of food, which deserve further discussion, are cereals, eggs, fruits and vege- 
tables. 

CEREAL. — Dietitians believe that a child's diet should contain some 
kind of cereal — i. e., a grain food other than flour or meal — every day. 
Those made from whole grain — whole wheat, whole rice, whole oats, whole 
corn — are the best, because they contain vitamins and other food elements 
that are lost in milling or refining. Home-cooked cereals are more valuable 
than prepared "breakfast foods," because they provide much more nourish- 
ment and cost much less. 

We find that nearly half the survey children ate cereal of some kind; 
in Greene, Harrison and Livingston Counties, the proportion rose to over 
half, while in Johnson and Mississippi Counties it fell to about one-third. 
The proportions were practically the same in town and country homes, and 
in the different age-groups. 

EGGS. — Eggs are highly recommended as food for children, particularly 
as substitutes for meat. As has been mentioned, eating eggs in the country 
— at least in rural Missouri — is largely a matter of season. In early spring, 
almost everybody eats eggs and eats them often (one child was recorded as 
eating six in one day); in late fall and winter, practically nobody eats them. 
Accordingly, we find that where the survey was made in the spring, most 
of the children had at least one egg a day (half in Greene County, nearly 
two-thirds in Livingston County). But in the other four counties, only 
from one-tenth to three-tenths of the children ate eggs. On this count — 
providing eggs in the "off" season — Mississippi County heads the list. 

FRUIT AND VEGETABLES.— Fresh fruit and fresh vegetables 1 are 
further types of food whose use depends largely upon the season. This is 
especially true of green vegetables. A growing number of families appre- 
ciate the value of fresh fruit sufficiently to buy oranges or sometimes apples 
and other "store fruit" when they have no home supply; but comparatively 
seldom do they buy "garden truck." 

Canned fruit is also much more common than canned vegetables; appar- 
ently this is due partly to the greater ease of canning fruit, and partly to 
habit. However, tomatoes are canned in large quantities, which is fortunate, 
because they are one of the most valuable vitamin-containing vegetables. 

Fruit preserved with sugar (preserves, jam, jelly, fruit butters) appears 
almost regularly on the large majority of country tables. While such fruit 
may possibly be more wholesome than none at all, it contains so much sugar 
that it cannot fill the place which fruit ought to hold in the diet; it belongs 
more with other "sweets" such as molasses and honey. Consequently such 
preserves are not counted as fulfilling the fruit requirements for a good diet. 

Five-eighths (62%) of the survey children ate some fruit (exclusive of 
preserves) during the sample day; one-sixth (17%) ate preserved fruit only; 
a little more than one-fifth (21%) had no fruit whatever. Of those who had 
fruit, nearly two-thirds (39%, or about three-eighths, of the whole) ate 
some raw fruit, while the others ate cooked or canned fruit only. 

l As noted under Diet Grades, the term "vegetable" in this discussion means 
vegetables other than white potatoes or dried legumes (peas, beans), both of 
which are staple articles of diet in rural Missouri. 

24 



In order to make sure of having all the kinds of vitamins (some of which 
may be destroyed by cooking), children should eat regularly some raw fruit 
or raw vegetables. That so large a proportion in this survey did eat raw 
fruit, is distinctly creditable in view of the fact that the survey was made 
mainly outside the fruit-producing season. 

In Greene County only, was any fruit (berries) coming to maturity at 
the time the records cover; and Greene County had next to the lowest pro- 
portion (23%) of children eating raw fruit. In Johnson and Nodaway Coun- 
ties records were taken in late fall and early winter, and show 58 per cent 
and 68 per cent of children eating raw fruit; this is accounted for largely 
by the fact that at that season fall fruit crops, stored for winter use, are 
available, though apples were somewhat scarce that year in Nodaway, and 
more families than usual had to buy fruit. 

In Harrison and Livingston Counties, where records were taken later in 
the year, but too early for spring fruits, the lower percentages — 38 per cent 
and 41 per cent — reflect the exhaustion of such stores. In all these northern 
counties, much more fruit was purchased than in the far-southern ones. 

The survey was carried out in Mississippi County at the same season 
as in Johnson and Nodaway Counties; yet, contrary to the findings in the 
two latter, only one in nine (11%) of the Mississippi County children was 
given any raw fruit. This is due largely to the fact that ordinary orchard 
fruits — apples, pears, peaches — grow poorly in that district. There is much 
less fruit than in other parts of the State, and what there is — berries, grapes, 
plums — comes earlier in the year, and is not available as raw fruit in the 
fall months. Farm housewives "put up" much of such fruit; but with their 
best efforts, less than half as many Mississippi County children had any 
fruit as in any one of the other counties. 

Fruit proved to be somewhat more plentiful in country homes than in 
villages, simply reflecting the fact that farmers have better chance to raise 
their own fruit supply than do villagers. 

When we come to the question of vegetables, we find a less favorable 
situation. Only 42 per cent of the children ate vegetables, as compared 
with 62% who ate fruit. And only 10 per cent had raw vegetables (lettuce, 
cabbage, celery, onions, etc.) as compared with 39 per cent eating raw fruit. 
It is interesting to find that 40 per cent of the Greene County children took 
advantage of early spring vegetables that can be eaten raw; while, as might 
be expected, in the winter-survey counties, raw vegetables were almost 
wholly absent. Mississippi County was second only to Greene County in 
utilization of raw vegetables, and stands far ahead of any other county in 
use of cooked vegetables,! thereby partly offsetting its scarcity of fruit. 

In the three northern counties, from one-fourth to one-third of the 
children ate some vegetable (other than white potatoes or dried beans); in 
Johnson County, two-fifths; in Greene County a little more than half; and 
in Mississippi County three-fifths. Rather contrary to expectation, we find 
that in Livingston County village children had vegetables about twice as 
often as country children; but in other places, the balance was the other 
way. 

1 In this territory, sweet potatoes, turnips and pumpkins were the common 
fall vegetables; but many families had greens of various kinds. 

25 



In connection with the requirement for a good diet, that it must contain 
either fruit or vegetable (as defined above), we find that four-fifths (79%) 
of the total met this requirement. Among rural children, this proportion 
was highest (about nine-tenths) in Johnson and Nodaway Counties, and 
lowest in Livingston and Mississippi Counties. A distinctly larger propor- 
tion of village diets failed on this point, than of those in the country. In 
other words, we have another case where village diets failed through com- 
parative deficiency. 

REGULARITY IN EATING. — In addition to containing the proper kinds 
of food, a really satisfactory diet should be eaten at regular hours, as a rule 
three times a day. It proved to be impossible to get reliable reports about 
hours for meals, especially in country homes. Meals on the farm are ordi- 
narily regulated by sun and season and by pressure of work, rather than by 
the clock. When children are going to school, that fact in itself exercises 
a regulating influence on their breakfast and dinner hour; but supper hours 
tend to be irregular, especially at busy times. About frequency of eating, 
however, considerable data were gathered. 

In the first place, it was found that about three-fourths of country 
children ate something when they came home from school — almost always a 
cold lunch chosen from whatever was left from the family dinner. This 
practice was also reported of five-eighths of village children. Many of these 
children habitually ate what amounted to a fourth meal at that time. 

It is natural enough that children who have a cold dinner, perhaps 
none too well relished, and, it may be, a long walk to and from school, 
should be hungry on reaching home. Indeed, some of the more careful 
mothers made a practice of having supper ready for the children when they 
came home, which is often as late as five o'clock. But in most families, this 
is impossible; and if supper must be late, it is desirable that hungry chil- 
dren should have something to eat — if only it could be selected with more 
judgment than is usually in evidence. The best solution of the problem 
would seem to be that something hot and wholesome be planned and ready, 
to take the place of the all-too-frequent "bread and butter and meat and 
pickles" or "bread and jam" or "pie." The records of what was eaten 
between meals furnish another illustration of the unwisdom of letting chil- 
dren choose their own food. 

Secondly, eating at recess is a common vice, especially among country 
children who take their dinners to school. The survey workers saw plenty 
of evidence of the prevalence of this custom. Many mothers expressed ignor- 
ance about their children's habits in this respect; but of those country 
children for whom the question was answered, fully half were reported as 
eating at recess. Among town children, this habit was naturally much less 
common (reported of only one-eighth). So far as the records show, the 
eating at recess habit was distinctly more prevalent among the younger 
childen, and decreased as they grew older. However, there is only a slight 
decrease in the habit of eating after school. 

Eating at both morning and afternoon recess, as well as at noon, puts 
the child's eating times only an hour and a half apart; and, with a lunch 
after school, means that he eats at least six times during the day. This is 
unquestionably too often. 

Thirdly, a certain proportion of children — about one-sixth — were reported 

26 



as eating between meals at other times than above mentioned. Further- 
more, about one in sixteen or seventeen was reported as given to "piecing" 
— i. e., frequent and irregular eating between meals, at any or all hours. 
This habit was more prevalent among country than among village children. 
It is one of the worst possible habits in eating, and one of the most unques- 
tionable reasons for classifying a child's diet as poor. Even the parents 
who acknowledged this failing in their children were aware that it was an 
unheal thful practice; those who made any serious attempt to oversee a 
child's diet usually affirmed, with pride, that he was "not allowed to piece." 

Fourthly, a number of children, about one in twenty, were found to 
have omitted i one of the three regular meals, either as a more or less 
regular custom, or sporadically without any particular excuse. The meal 
most often omitted is breakfast; some children refuse to eat any dinner 
when going to school; supper is the one least often neglected. For a school 
child to leave out any one of his three regular meals is almost sure to 
result in insufficient food-intake, and extremely liable to cause malnutrition. 
When it is breakfast or dinner that is lacking, the child's system is robbed 
of its proper nourishment during the hours when he is most active, at study 
and at play, and his whole body is most in need of replenishment. 

The foregoing discussion applies to irregularity in eating during the 
school term. In Greene County, diet records for 120 children were secured 
after schools had closed for the summer; from these, we can get some idea 
of what the children do when not attending school. The records show a 
little more than half the children eating between meals. This habit de- 
creased markedly as they grew older; under 10 years old, five-eighths 
(62%) ate between meals, but beyond that age only three-eighths (37%) 
did so. 

SUMMARY. — With a few exceptions, the defects of diet noted in this 
report were not due to poverty. Some country families are poor to the 
extent of having neither cow nor garden; but it would be difficult to prove 
that poverty was the only, or even the chief, cause of the limited diet upon 
which such families live. 

In the main, it may be said that the difficulty lies in ignorance; first, 
as to what constitutes a wholesome, properly balanced diet for adult or 
child; second, as to the fact that certain foods which are harmless for 
.adults are unsuitable for children. Country people know that young ani- 
mals — chickens, for example — must be fed differently from full-grown ones; 
but they fail to apply this knowledge to their own children. 

A secondary factor is the tendency — by no means confined to the 
country — to allow children to do pretty much as they desire, to go to bed 
when they wish, to eat what and when they want. Good health can never 
be built up on that basis. Marvelously much can be accomplished in enlist- 
ing the child's co-operation to that end; but there must be some parental 
control in the background. 

l Either omitted entirely or reduced to practically negligible food — e. g., a cup 
of coffee only. 



27 



CONCLUSION. 

"What to Do About It." 

Whenever an unsatisfactory condition in human affairs is discovered, 
the question arises as to what can be done to improve the situation. That 
physical defects among children cannot be counted upon to cure themselves 
is demonstrated by the great number of defects found among young adults 
whenever they are examined in large numbers; for example, by the Army 
Draft Examination in 1917 and 1918, which showed that one-third of Ameri- 
can young men in the prime of life were physically unfit for military serv- 
ice. It should be remembered that the examining physicians at that time 
found that a large proportion of the disqualifying defects could have been 
prevented or cured if they had received proper attention during the boys' 
early years. 

I. Remedial Measures. 

We are confronted with an enormous number of remediable defects 
among Missouri children — now, as an actual present condition. What can 
be done about it? This is fundamentally a medical problem, and must be 
worked out in co-operation with the organized physicians of the State. With 
this in mind, the following suggestions are offered as a tentative outline of a 
plan to meet the situation: 

(a) Physical Examinations for all school children, to be extended to 
children under school age when practicable. (Many defects — e. g., decayed 
teeth and infected tonsils and adenoids — 'develop and need attention before 
the child reaches school age.) This is the logical first step, for we cannot 
expect to remedy defects until we know, specifically and individually, where 
they are. But it is to be looked upon as only the first step in an effective 
remedial program. 

If this work is to be done regularly and for all children, it must be 
paid for, as is done in all large cities; physicians must not be called upon 
to donate such an amount of service, no matter how public-spirited they 
may be. In rural Missouri, outside of the cities employing city or school 
physicians, the full-time county health officer plan seems the most feasible 
way to secure such service. It naturally would be combined with the 
supervision of health conditions in the schools, which many part-time county 
officers now undertake. Eleven Missouri counties now (June, 1922) have 
full-time health officers, and it is to be hoped that the list will grow rapidly. 

(b) Follow-up Work. — Most places which have tried physical examina- 
tions without "Follow-up" have found that they did not get very far. Dis- 
covery of defect doesn't help much unless it is corrected. And everywhere, 
there is a considerable proportion of parents who do not take any action 
unless someone personally persuades them to do so. This neglect may be 
due to inertia, to lack of understanding, to disinclination to give the child 
pain, or to a feeling of helplessness; but it needs personal contact and 
persuasion, in many cases, to overcome it. 

The logical person to perform this service is the school nurse (usually 
in the larger towns), or the county public health nurse for the open country. 
It is a big job, but the county nurses do manage to handle much of it. 
And where no medical service is available, a public health nurse can do a 

28 



great deal of good in examining school children, as well as in her other 
lines of duty. A public health nurse is an investment in health which no 
public-spirited or truly thrifty county should be willing to do without. 

(c) Children's Clinics. — Nevertheless, with the best follow-up work pos- 
sible, the problem has not been fully met, because there are everywhere 
some parents, more or less numerous, according to local economic condi- 
tions, who cannot afford the expense customarily involved in such remedial 
work as may be needed. This is where country children are distinctly worse 
off than city children. No matter how poor a city child's parents may be, 
the school nurse in a place like Kansas City or St. Louis can arrange to get 
his tonsils removed, or his teeth filled, at an institution carried on for that 
purpose. But in none of the counties of the survey — and they were by no 
means poor or backward as Missouri counties go — was there any organized 
service of this kind at the time the survey was made. Unquestionably it 
would have been possible to have individual children cared for through an 
appeal to the charitable impulses of individual physicians; but that is a very 
different thing. 

In addition, dental service, and even more, specialized surgical or ocu- 
list's service, commonly means for country people a journey away from 
home, often a journey of considerable length; this is an additional expense, 
which city folks do not have to meet. Judging from the survey experience, 
the smaller country towns (under 500 population) in Missouri seldom have 
resident dentists, and only a few have the service of a visiting dentist. 
Many country people are within practicable driving distance only of such 
small centers. This is even more true of the rougher parts of the State, 
not reached by the survey. 

While all the survey districts had available the service of general prac- 
titioners, only very few of these physicians were prepared to undertake 
surgical work. In four out of the six counties, there were nose and throat 
specialists at the county seat, equipped to remove tonsils and adenoids; in 
the other two, a trip to the nearest urban center (outside the county) was 
necessary for such an operation. In the same two counties, a journey was 
necessary to secure expert oculist's advice. (Of course, a good many people 
in all six counties patronized home-town or itinerant opticians, but that is 
another story.). In respect to such specialists' service, the survey counties 
probably averaged well above rural Missouri as a whole. 

Under these circumstances, Missouri citizens should give heed to the 
fact that other states are forging ahead of Missouri in providing for rural 
children. For example, Kansas is planning a campaign for adequate medical 
care for children throughout the State; Minnesota sends out traveling rural 
clinics which devote much of their attention to children. North Carolina has 
actually in operation the most comprehensive service for country children 
which has come to the writer's knowledge. 

Finding among their rural children the same conditions which exist in 
Missouri — thousands who needed dental and surgical care for whom there 
was no prospect of securing such care — the North Carolina Board of Health 
set out to do something about it. What they have done is to provide free 
dental clinics and to arrange what they call a "club plan" for tonsil 
operations. 

29 



The dental clinic work is done by dentists employed by the State Board 
of Health, who travel by automobile through their assigned territory on 
itineraries arranged by the county school or health authorities, working in 
school houses, court houses, etc. The service is restricted to school children 
from six to thirteen years old, who are selected by the local authorities. As 
stated by the Board: "The clinics are open to all classes alike; * * it 

is a free clinic paid for out of public funds, just as the public school is 
supported"; because "poverty is by no means the most important cause of 
dental neglect." (Poverty is elsewhere listed as sixth in order of importance 
among causes, with ignorance first, and indifference second.) The Board 
reports that up to the end of 1921 (beginning apparently in 1919), 66,452 
children in sixty-five counties received treatment in these dental clinics. 

The North Carolina tonsil-and-adenoid clinics, on the contrary, have 
been carried out on a pay basis; the reason given for this difference being: 
"We have considered that our basic effort should be the permanent introduc- 
tion of the capable operators of each section to the people who most need 
their service. * * * So we have employed men of established reputation 
in their communities." The surgeon is paid for this service; and for each 
child a fee of $12.50 is charged, except that a certain proportion (up to one- 
fourth of the total) may be accepted without payment. It is found that the 
expenses of the clinic may be met on this basis. The State Board of Health 
provides nurses to make arrangements, select patients, and care for the 
children at the time of the operation and afterward; and also an assisting 
physician to give preliminary examinations and act as anesthetist. Cots 
and other necessary hospital equipment are set up in a school or other 
suitable building; children are kept there in bed after the operation until 
at least the following day, under the care of a trained nurse. 

Under this plan it is reported that clinics have been conducted "in 
forty-eight counties, operating on 3,595 children, most of whom would never 
have had a chance otherwise." 

There seems to be no reason why eye clinics, operated on a similar 
"club-payment" basis, would not be of equally great service. Indeed, a plan 
similar in principle was suggested to the survey director by a local physi- 
cian in one of the Missouri counties lacking a local oculist, as a solution 
of the defective vision problem among school children. This physician rec- 
ommended that parents of children with eye trouble should club together 
and employ an oculist from the nearest city to come to their county seat, 
examine the children's eyes and prescribe as needed. But in practice it 
usually requires some interested outsider — for example, an active county 
nurse — to take the necessary first steps toward even such an informal co- 
operative scheme. 

Another way to make surgical service more available to country people 
would be to establish and maintain general hospitals from county funds, as 
is permitted by law in Missouri. Most of the counties included in this 
survey had at least one hospital, operated by individuals or by private 
organizations, at the county seat; but many Missouri counties have no such 
facilities. 

II. Preventive Measures. 

Of course, the ultimate aim of public health work is to prevent, rather 
than cure, physical defects and disease. Unfortunately there is still a great 

30 



deal to learn about why one child has sound teeth and another not; why 
defective tonsils and adenoids afflict one child and not another; why one 
child reaches school age with poor refraction and another with perfect 
vision. But some things seem well established: for instance, that proper 
food has a great deal to do with general nutrition, and probably, from the 
beginning of life, with teeth; that personal cleanliness does help in preser- 
vation of teeth and in prevention of contagious disease, including colds; 
that sufficient, wholesome sleep has much to do with growth and with pre- 
vention of nervousness, often an important factor in malnutrition; that 
better ventilation and avoidance of colds are our "best bet" so far in trying 
to decrease the number of tonsils and adenoids needing to be removed. 

Taking up such measures in the order in which the present status was 
discussed from the home records, the following suggestions are made: 

(a) Home Sanitation. — "What is needed here is the spread of knowledge 
about the fundamental principles of sanitation as applied to the country 
home, i. e., safe water supply, disposal of human wastes, screening as a 
preventive of fly-borne and mosquito-borne disease. These topics are in- 
cluded in the State course of study for elementary schools in the work on 
hygiene, though not given the importance they deserve. The problems of 
household water supply are also taken up under "Home Conveniences" in 
the agricultural course. This teaching should help, in time, to remove the 
deficiencies along these lines which the survey has revealed. The Home 
Bureau and the Farm Bureau, where they are established, are doing a great 
deal to further the physical improvement of rural homes. Such teaching, 
both for children and for adults, should be pushed as far as possible. 

But equally important is the economic problem; home improvements, 
unfortunately, cost money. By and large, the people who live in unsanitary 
homes are those who cannot afford better. The exceptional cases — e. g., 
failure to provide even the most primitive toilet facilities in the far-southern 
counties — must be reached by education. The main bulk of improvement 
must depend upon agricultural prosperity. 

(b) Personal Hygiene. — The most promising method of teaching the 
practical observance of health habits is the School Health Crusade, intro- 
duced in Missouri by the Missouri Tuberculosis Association and widely 
adopted among the schools of the State. The survey workers had many 
opportunities to observe and learn from parents that where the Health 
Crusade was being carried out in the community school, it made a marked 
difference in the children's attitude towards cleaning teeth, taking baths, 
going to bed early, etc. Parents, and others interested in better health, 
should see to it that some such plan involving actual practice of good 
habits is carried out in all schools. It is a wonderful help to parents who 
are trying to teach these same habits, and also enlists the efforts of many 
pupils whose parents are not especially interested. 

(c) Diet. — The problem of improving food habits is one of the most 
difficult phases of health education, because in many respects sound teaching 
goes directly contrary not only to established habits, but also to established 
likings. For instance, few people really prefer to be untidy or dirty — it is 
just too much trouble to keep clean; but many people really like hot biscuits 
and pancakes and fried meat and pickles. And as long as the adults of a 
community live on such things it is hardly to be expected that in the ordi- 

31 



nary home a different menu will be provided for the children. 

Here, again, we must be patient, and fall back upon education through 
all possible channels. The various Home Economics extension services, the 
county Home Bureaus and the Red Cross are doing much work along these 
lines — the only work that so far really seems to be "getting across." The 
routine school teaching on diet does not seem to make much impression; 
perhaps the subject as a whole is too complicated for children or perhaps — 
like much school teaching — it seems too detached from every-day life. 

On some one simple, concrete and practicable item, like the substitution 
of milk for coffee, the Health Crusade or similar scheme may, and often 
does, bring about a change. But it would do very little good to tell a child 
to eat light-bread instead of biscuits, if his mother never makes light-bread. 

School Lunches. — One concrete, practical way in which the school can 
make a dent in the food problem is by means of hot school lunches. In this 
way, not only may children be taught to eat and like wholesome dishes 
which perhaps they had avoided or had not known, but they also are given 
a hot and nourishing noonday meal. This is particularly valuable in rural 
schools, where few pupils can go home for dinner; and it is generally appre- 
ciated by thoughtful parents. 

The school lunch is a trying problem to a busy country mother, no 
matter how careful she may be; if she is not particularly careful, her chil- 
dren are often left to pick out and pack their own lunches from whatever 
they find on the breakfast table or in the kitchen cabinet. Consequently the 
"bread and ham, bread and jam, pie" type of lunch is all too common. 
Furthermore, the country family usually has its dinner at noon. The adults 
and small children then have a substantial meal; and a light supper requir- 
ing little cooking seems natural and proper. But meantime the school 
children have had, perhaps, cold biscuits and ham, a cold fried egg, pie or 
cake. With a cold "piece," say of bread and preserves, after school and 
the aforementioned light supper, a rather inadequate day's diet is bound to 
result. 

A "school lunch," consisting of some especially nourishing hot dish 
cooked and served at school — e. g., cream-vegetable soups or milk-cocoa — 
added to the "dinner" brought from home, helps the situation materially. 
The preparation and serving of a one-dish lunch has proved feasible in rural 
schools in many places. Most simply, the cooking equipment is bought from 
money raised at a school entertainment; the pupils bring their own dishes; 
and the food-materials are furnished co-operatively by the parents.* 

A group of parents actively interested in the health of their children 
could hardly do any one thing more helpful than to persuade the school 
teacher to have hot lunches, and help her carry out the plan. 

1 Detailed suggestions for the management of school lunches may be secured 
from the Agricultural Extension Division of the State University at Columbia, 
Missouri, or from the United States Bureau of Education in Washington (Health 
Education Bulletin No. 7 — "The Lunch Hour at School"). 



32 



SUMMARY OF RECOMMENDATIONS. 

1. Employ full-time county health officers, and include in their duties, 
giving physical examinations to all school children not already under the 
care of school or city physicians. 

2. Employ county public health nurses, who (among their manifold 
duties) shall assist in school examinations and follow up children in need 
of treatment. 

3. Establish some plan whereby children who need dental, surgical or 
oculist's care can get it, even if they do not live in a large city. 

4. Develop the practical bearing of school instruction in hygiene, espe- 
cially along the lines of sanitation and food-selection. 

5. Push the Missouri School Health Crusade. 

6. Establish hot school lunches in country schools. 

7. Back up and extend the health-education work of the Farm Bureaus, 
the Home Bureaus, the Red Cross Chapters, and the Missouri Tuberculosis 
Association. 



This survey has been paid for from the proceeds of the sale of Tuberculosis 
Christmas Seals. 



33 



Physical Examination I. 

WEIGHT DEVIATION 

Percentage of grade pupils deviating from standard weight as specified. 



County 



Total 
number 
weighed 



• >' , or more 
BELOW 



10% 

or 
more 



5 to 

10% 



Within 

o /O 



o' ( or more ABOVE 



5 to 
10% 



10 to 

15% 



15% 

or 
more 



All children: 
Total... 



Greene. . . . 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston. 
Mississippi. 



1897 



237 
328 

159 
291 
581 
301 



19.8 



23.2 
21.0 
10.7 
17.9 
23.1 
16.3 



22 1 



40.5 



9.2 



22.8 
21.7 
17.6 
23.4 
23.4 
20.6 



40.5 
38.7 
55.3 
37.8 
38.5 
40.9 



7.6 
8.5 
8.2 
8.9 
9.5 
11.6 



3.9 



3.0 
4.9 
2.5 
5.8 
2.4 
5.0 



4.5 



2.9 
5.2 
5.7 
6.2 
3.1 
5.6 



Rural children: 
Total 



Greene .... 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston . 
Mississippi. 



1327 



17.9 



22 4 



41.0 



9.8 



210 
243 
159 
140 
307 
268 



23.3 

21.0 
10.7 
12.9 
18.9 
16.8 



22.9 
24.3 
17.6 
25.7 
22.8 
20.9 



40.0 
36.6 
55.3 
34 . 3 

41.7 
39.9 



7.6 
8.2 
8.2 

14.3 
9.8 

11.6 



3.9 



2.9 
3.7 
2.5 
5.7 
3.6 
5.2 



5.0 



3.3 
6.2 
5.7 
7.1 
3.2 
5.6 



Town children: 
Total 



Greene*. . . 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston. 
Mississippi 1 



570 



24.2 



21.4 



39.3 



7.9 



27 
85 



151 

274 
33 



22.2 
21 .2 
None i 
22.5 
27.7 
12.1 



22.2 
14. 1 
nclude 
21 2 
24.1 
18.2 



44.5 
44.7 
d in su 
41.0 
35.1 
48.5 



7.4 
9.4 
rvey . 
4.0 
9.1 
12.1 



3.7 



3.7 

8.2 



6.0 

1.1 
3.0 



3.5 



2.4 



5.3 
2.9 
6.1 



Too few for reliable percentages. 



34 



Physical Examination II. 

CONDITION OF PERMANENT TEETH 

Percent of grade pupils of specified ages, having unfilled cavities, fillings or 
extractions in permanent teeth. 





10 years of 


age or 


over 


12 j^ears of 


age or 


over 


County 


Nor- 
mal 


Unfilled 
cavities 


Fill- 
ings 
or 
extrac- 
tions 


Nor- 
mal 


Unfilled 
cavities 


Fill- 
ings 
or 




Total 


Alone 


Total 


Alone 


extrac- 
tions 


All children: 


















Total 


41.7 


46.8 


37.1 


21.2 


35.2 


50.2 


37.3 


27.5 




32.6 
40.2 


51.6 
48.9 


34.9 
35.3 


32.5 
24.5 


22.4 
32.4 


59.2 
53.9 


36.8 
34.3 


40.8 


Johnson 


33.3 


Nodaway 


49.5 


38.7 


34.4 


16.1 


49.0 


40.4 


31.9 


19.1 


Harrison 


44.1 


46.4 


40.1 


15.8 


37.1 


50.9 


43.1 


19.8 


Livingston 


37.6 


46.9 


35.2 


27.2 


30.2 


47.2 


33.6 


36.2 


Mississippi 


51.1 


46.1 


42.2 


6.7 


49.0 


49.0 


43.3 


7.7 


Rural children: 


















Total 


44.0 


44.7 


36.4 


19.6 


38.0 


47.7 


36.6 


25.4 






Greene 


33.1 
47.0 


50.0 
43.3 


35.7 
32.8 


31.2 
20.2 


22.1 
37.8 


57.4 
48.6 


38.2 
33.8 


39.7 


Johnson 


28.4 


Nodaway 


49.5 


38.7 


34.4 


16.1 


49.0 


40.4 


31.9 


19.1 


Harrison 


50.6 


38.6 


34.9 


14.5 


41.0 


47.5 


44.2 


14.8 


Livingston 


37.1 


46.2 


35.5 


27.4 


32.4 


43.5 


30.6 


37.0 


Mississippi 


51.0 


47.2 


42.7 


6.3 


49.0 


48.9 


42.3 


8.7 


Town children: 


















Total 


36.3 


51.8 


38.7 


25.0 


28.8 


55.6 


38.7 


32.5 


Greene* 


28.6 


64.3 


28.6 


42.8 


25.0 


75.0 


25.0 


50.0 


Johnson 


22.0 


64.0 


42.0 


36.0 


17.9 


67.8 


35.7 


46.4 












d in su 








Harrison 


38.3 
38.3 


53.2 
47.6 


44.7 
34.9 


17.0 
26.8 


32.7 
27.5 


54.5 
51.6 


41.8 
37.3 


25.5 


Livingston 


35.2 


Mississippi* 


52.4 


38.1 


38.1 


9.5 


50.0 


50.0 


50.0 





*Too few for reliable percentages. 



35 



Physical Examination Summary 

OCCURRENCE OF COMMON PHYSICAL DEFECTS 

Percent of grade pupils found to have specified defect. 



County 



l-i Ml 

as? 



2*d 

,2 <u 

cl> 



o 



OT 6 

tn «H «) 

c 3 — 
o 



(/-. TD 



J. <u 

(L> — . 

ft |*S 

to °< a 
•a w 

"6 *£ 5 

c H 

0) <L> »- 

« !D C 



a> o © 

?£€ 

> ~ 0) 
2 O t- 

° 3 8 



All children: 

Total 


19.8 


69.5 


46.8 


44.5 


37.8 


22.5 


28.8 


31.2 


Greene 


23.2 
21.0 
10.7 
17.9 
23.1 
16.3 


73.2 
72.5 
67.0 
71.6 
70.3 
61.3 


51.6 
48.9 
38.7 

46.4 
46.9 

46.1 


39.2 
54.2 
36.8 

47.0 
42.2 
44.2 


48.9 
47.8 
29.5 
38.1 
25.7 
43.9 


21.6 
19.0 
24.8 
27.4 
20.8 
24.5 


16.0 
30.9 
31.7 
31.0 
29.9 
31.0 


18.2 


Nodaway 

Harrison 

Livingston 

Mississippi 


34.7 
32.3 
31.7 
33.9 
31.7 


Rural children: 

Total 


17.9 


67.6 


44.7 


45.3 


38.3 


21.8 


27.2 


29.2 






Greene 

Johnson 


23.3 
21.0 

10.7 
12.9 
18.9 
16.8 


72.2 
70.2 
67.0 
70.4 
67.5 
60.6 


50.0 
43.3 
38.7 
38.6 
46.2 
47.2 


39.0 
56.1 
36.8 
45.4 
45.8 
45.0 


51.0 
43.3 
29.5 
38.5 
25.4 
43.5 


21.5 
17.2 
24.8 
27.7 
19.7 
23.7 


15.6 
29.4 
31.7 
28.2 
28.9 
29.3 


18.0 
31.5 


Nodaway 

Harrison 

Livingston 

Mississippi 


32.3 
29.0 
32.8 
30.0 


Town children: 

Total 


24.2 


74.0 


51.8 


42.6 


36.3 


24.2 


32.5 


35.9 


Greene* 

Johnson 

Nodaway 


22.2 

21.2 


81.5 
78.5 


64.3 
64.0 
None i 
53.2 
47.6 
38.1 


40.7 
48.8 
nclud e 
48.4 
37.8 
37.5 


33.3 
60.7 
d in su 
37.8 
26.0 
46.9 


22.2 
23.8 


18.5 
35.3 


18.5 
43.5 


Harrison 

Livingston 

Mississippi* 


22.5 

27.7 
12.1 


72.6 
73.4 
67.6 


27.2 
22.0 
31.2 


33.3 
31.0 
45.4 


34.0 
35.1 
45.4 



*Too few for reliable percentages. 



36 



Physical Examination: High School Summary 

OCCURRENCE OF COMMON PHYSICAL DEFECTS 

Percent of High School pupils found to have specified defect. 



-■ 












, 


CD 




u 


a 


"73 O 


CD.-H 


a 




> 








CD 


ds pr 

probab 

spected 


>> o 




County 


T3 
S 

CD rj 

"*> 

CD <U 
P.JJE 


a 

u 

T3 m 


enlarg 
lerged 
sed 


CD 


CD O 

CD ^-~ 
> T3 


O 

CD 

V 




4) w 

as 


Dnsils 
subn 
disea 


denoi 
sent, 
or st] 


O 


efecti 
sight 
recte 


o 




H 


Q 


e 


< 


S 


Q 


EH 


All Children: 








■ ■•■ 








Total 


13.7 


43.2 


38.4 


13.3 


9.5 


21.6 


31.7 






















Not 












Johnson 


12.1 


exam. 


32. 7 3 


34. 6 3 


18.2 


16.4 


32.8 


















Harrison 


12.1 


57. I 2 


52.8 


10.6 


11.4 


20.8 


23.3 


Livingston 


14.3 


34.2 


24.1 


3.7 


3.8 


23.8 


36.9 








None i 


nclud e 


d in su 


rvey . . 















*Too few examined to calculate percentages, 
including those wearing glasses. 
2 Dentist's examination. 
'Examination by nose-and-throat specialist. 



37 



Home Sanitation Summary 

Percent of homes found to have conditions specified. 





£ S 

o o 

U. o 

CI * 

C u 
*-" CD 

0) c 

k ° 


O— ' 


CD 

,4 

<t> 
T) 

'5; 

C 

CD ^ 
43 O 


O.J2 

C/5 O 

4) . 


V 

in 

O 

u 


>> 

> 
°C 

44 


s 

a 
O 




"0 

+-> 




Screening 


County 


CD 

H 

a 






CD 

a 




All homes: 

Total 


11.3 


12.3 


8.7 


2.3 


2.4 


18.4 


7.4 


71.9 


4.3 






Greene 


17.5 
9.1 
3.8 
5.8 
6.2 

22.5 


14.6 

12.9 

7.5 

4.7 

2.6 

28.8 


8.8 

7.3 

18.8 

12.9 

7.7 
4.0 


4.4 
4.0 
1.3 

2.6 


0.7 
1.1 
6.3 
7.1 
2.1 
1.3 


13.1 
19.1 
10.0 
4.7 
14.9 
38.9 


17.5 
3.9 
2.5 
1.2 
3.6 

13.4 


66.4 
59.9 
88.6 
81.2 
84.4 
60.8 


5.1 
6.2 


Nodaway 




Harrison 


1.2 


Livingston 

Mississippi 


1.6 

8.8 


Rural homes: 

Total 


12.1 


14.4 


8.5 


2.9 


1.9 


24.4 


10.0 


67.6 


5.2 






Greene 


19.0 
7.0 
3.8 


15.7 

13.0 

7.5 


8.3 

6.1 

18.8 

. . No 


5.0 
5.4 
1.3 
recor 
2.6 


0.8 
0.8 
6.3 

ds se 
1.7 
1.5 


14.9 
24.4 
10.0 
cured 
23.4 
42.7 


19.8 
5.3 
2.5 


64.5 
54.6 
88.6 


5.8 


Johnson 


5.9 


Nodaway 








Livingston 

Mississippi 


3.5 
24.0 


3.5 

28.2 


11.3 
2.3 


4.3 
15.3 


82.3 

57.7 


1.8 

9.2 


Town homes: 

Total 


9.3 


7.3 


9.4 


0.8 


3.7 


4.1 


1.2 


82.1 


2.0 






Greene* 


6.3 
14.9 


6.2 
12.8 


12.5 
10.6 
None 
12.9 
2.5 
16.7 










81.2 
74.5 




Johnson 


inclu 
2.5 


2.1 
ded i 

7.1 
2.5 


4.3 

n sur 

4.7 

2.5 

11.1 


vey . . 


4.2 


Nodaway 




Harrison 


5.8 
10.3 
11.1 


4.7 

1.3 

33.3 


1.2 
2.5 


81.2 
87.3 
83.3 


1.2 


Livingston 


1.3 


Mississippi* 


5.6 









"Too few for reliable percentages. 



38 



Personal Hygiene Summary 

I. SLEEPING CONDITIONS AND HOURS 

Percent of children having specified habits. 





Bed room win- 
dow open in 
winter 


Sleeping in room with 


Sleeping in bed 
with 2 or more 
others 

... 


U QJ 

cc QJ 


County 


in 

as 


QJ 
!-. 

o 

a e 

° O 


4 or more 
others and 
wind ows 
closed i n 
winter 


a o 


All Children: 

Total 


53.4 


54.6 


11.1 


6.0 


13.6 


65.2 


Greene 

Johnson 

Nodaway 

Harrison 

Livingston 

Mississippi 


42.4 
55.8 
80.3 
64.0 
68.4 
22.7 


55.9 

58.7 
57.6 
46.9 
45.3 
62.6 


8.0 

10.2 

18.5 

4.0 

9.2 

16.4 


6.3 
5.3 
3.3 
0.8 
3.6 
13.3 


9.7 
15.8 
14.6 

8.7 
11.7 
18.9 


59.2 
68.5 
68.8 

85.4 
69.5 
50.7 


Rural children: 

Total 


51.9 


56.6 


12.8 


7.2 


14.4 


62.2 


Greene 

Johnson 

Nodaway 

Harrison 


38.1 
58.3 
80.3 


57.3 
59.2 
57.6 
No 


8.1 
11.3 
18.5 
records 
10.6 
16.6 


7.1 
5.5 
3.3 
secured . 


10.9 
18.1 
14.6 


59.4 
66.5 
6S.8 


Livingston 

Mississippi 


73.8 
22.5 


44.0 
63.6 


4.1 
13.8 


8.3 
19.0 


67.1 
52.6 


Town children: 

Total 


57.1 


49.6 


6.8 


2.9 


11.9 


72.8 




77.0 
48.8 


44.4 
57.1 


7.4 
7.1 
included 
4.0 
7.0 
15.1 






57.7 


Johnson 


4.8 
in surve 
0.8 
2.8 
9.1 


9.5 


73.8 


Harrison 

Livingston 

Mississippi * 


64.0 
60.0 
24.3 


46.9 

47.1 
54.5 


8.7 
16.9 
18.1 


85.4 
72.9 
36.4 



"Too few for reliable percentages. 



39 



Personal Hygiene Summary 

II. PERSONAL CLEANLINESS 

Percent of children having specified habits. 





Baths per week 


Cleaning teeth 






Boys 




County 


Winter 
1 or 
more 


Summer 
2 or 
more 


Girls 




Regu- 
larly 


Never 


Regu- 
larly 


Never 


All children: 

Total 


73.3 


78.9 


22.8 


20.7 


42.1 


10.9 


Greene 

Johnson 

Nodaway 

Harrison 

Livingston 

Mississippi 


68.5 
82.9 
81.2 
83.3 
89.0 
36.7 


61.3 

87.7 
76.8 
91.9 
84.5 
72.0 


14.8 
22.5 
44.1 
36.6 
18.5 
17.1 


32.2 
21.3 
10.4 
1.4 
6.9 
43.9 


33.3 

47.0 
55.9 
49.1 
37.1 
41.0 


13.0 

19.0 

2.9 

5.9 

15.0 


Rural children: 

Total 


70.3 


77.5 


22.2 


25.5 


41.2 


13.0 


Greene 

Johnson 

Nodaway 


66.9 
84.8 
81.2 


64.0 
90.6 

76.8 


12.5 
25.6 

44.1 

No recor 

17.7 

17.5 


35.6 

22.4 

10.4 

ds secure 

7.1 

46.0 


29.0 

46.0 

55.9 

d 


15.0 

21.2 

2.9 


Livingston 

Mississippi 


90.2 
34.8 


84.1 
71.4 


37.2 
43.0 


5.7 
15.8 


Town children: 

Total 


80.8 


82.4 


24.3 


9.0 


44.4 


5.3 


Greene* 

Johnson 


81.5 

77.4 


40.7 
79.5 


36.4 
13.6 
ncluded i 
36.6 
19.7 
15.0 


18.2 
n survey 
1 .4 
6.6 

30.(1 


62.5 
50.0 


12.5 


Harrison 


83.3 
87.2 
51.5 


«)1.9 
85.2 
75.8 


49.1 
36.9 

23.1 




Livingston 

Mississippi* 


6.2 

7 . 7 



*Too few for reliable percentages. 



40 



Diet Summary I. 

DIET GRADE 

Percent of children under 16 years of age having diet of specified grade. 



County 



Total 
num- 
ber 
of 
reports 



Percent 



Good 



Me- 
dium 



Poor 



Inade- 
quate 



Good 
plus 
Me- 
dium 



Poor 

plus 
Inade- 
quate 



All children: 
Total . . 



Greene. . . . 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston . 
Mississippi, 



Rural children: 
Total 



Greene .... 
Johnson. . . 
Nodaway. . 
Harrison . . . 
Livingston . 
Mississippi. 



Town children: 
Total 



Greene*. . . 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston. 
Mississippi' 



1431 



3.9 



28.5 



63.7 



225 
310 
148 
116 
350 
282 



4.9 
1.9 

4.1 
4.3 

7.4 
0.7 



28.4 
28.4 
37.1 
31.9 
39.4 
8.9 



61.8 
66.1 

57.5 
53.5 
48.9 
88.6 



1034 



3.1 



28.2 



66.0 



199 
226 
148 



5.0 
0.9 
4.1 



212 
249 



5.7 
0.8 



29.2 
30.1 
37.1 
No rec 
43.4 
7.6 



61.8 
65.0 
57.5 
ords se 
49.0 
89.5 



397 



6.0 



29.0 



57.9 



26 
84 



3.8 



116 

138 
33 



4.3 
10.1 



23.1 
23.8 
None i 
31.9 
33.4 
18.2 



61.6 
69.0 
n elude 
53.5 
48.5 
81.8 



3.9 



32.4 



4.9 

3.6 

1.3 

10.3 

4.3 
1.8 



33.3 
30.3 
41.2 
36.2 
46.8 
9.6 



2.7 



31.3 



4.0 
4.0 
1.3 
cured . 
1.9 
2.1 



34.2 
31.0 
41.2 



49.1 
8.4 



7.1 



35.0 



11.5 

2.4 

d in su 

10.3 

8.0 



26.9 
28.6 
rvey . . 
36.2 
43.5 
18.2 



67.6 



66.7 
69.7 
58.8 
63.8 
53.2 
90.4 



68.7 



65.8 
69.0 
58.8 



50.9 
91.6 



65.0 



73.1 
71.4 



63.8 
56.5 
81.8 



"Too few for reliable percentages. 



41 



Diet Summary II. 

REASONS FOR POOR GRADE IN DIET 

Number of children whose diet was poor because of specified reasons. 





o 

to 

o 
O 


'{3 

c 
"3 


o 
C 

CO 

O 


o 

W 'Tr. 

'3 *<-> 
o * 

tS) o 

PQ 


1- tu 

•'- p 

C G3 

C rt 

g.3 

« t- 

lH 


ID 
O 

O 


O 

cs 

t/2 

1/1 

o 


'V 
o 

1 

c 

*c3 

o 


o 
Eh 


Special 


County 


o 

.O 

E 
z 


Specifica- 
tion 


All children: 
Total 


329 


355 


309 


298 


82 


62 


49 


43 


21 


8< 


5-pie 3 times 
2-pie in even- 
ing. 
1-6 eggs 


Greene 

Johnson 

Nodaway. . . . 
Harrison 

Livingston . . . 

Mississippi.. . 


63 
61 
27 
15 

70 

93 


48 
96 
20 
30 

69 

92 


34 
88 
45 
12 

41 

89 


48 

37 

4 

1 

1 
207 


13 

10 

1 

3 

24 

25 


8 
13 

9 
12 

11 

9 


4 

17 

2 

7 
19 


3 
6 
3 
6 

14 

11 


2 

4 

1 
10 

4 


2 
2 

3 
I 
1 


pie 3 times 
pie in evening 

2-pie 3 times 
1-6 eggs 
pie 3 times 


Rural children: 
Total 


247 


245 


248 


263 


68 


35 


43 


27 


13 


J 

I 


3-pie 3 times 
2-pie in even- 
ing 


Greene 

Johnson ..... 
Nodaway. . . . 
Harrison 


53 
44 

27 


45 
66 
20 


34 

67 
45 


45 

29 

4 

No 
1 
184 


11 
12 
1 
reco 
19 
25 


5 
5 
9 

rds s 
8 
8 


4 
13 

2 
ecur 

5 
19 


2 
5 
3 

ed 


2 
3 


2 
2 


pie 3 times 
pie in evening 


Livingston... . 
Mississippi. . . 


43 

80 


30 
84 


28 
74 


10 

' 7 


4 

4 


1 


pie 3 times 


Town children: 
Total. 


82 


110 


61 


35 


14 


27 


6 


16 


8 


f 

4 


2-pie 3 times 
1-6 eggs 


Greene* 


10 

17 


d 

30 


21 

Non 

12 

13 

15 


3 

8 

e inc 

1 

23 


2 

4 

lude 

o 

5 


3 

8 

d in 

12 

3 

1 


4 

sur 

2 


1 
1 








Johnson 

Nodaway. . . . 


1 






Harrison 

Livingston. . . 
Mississippi*. . 


15 
27 
13 


30 

39 

8 


6 
4 
4 


1 
6 


3 i 


2-pie 3 times 
1-6 eggs 



*Too few for reliable percentages. 



42 



Diet Summary III. 

USE OF MILK 

Percent of children under 16 years of age, using milk as specified. 



Countv 



Total 
number 

of 
reports 



PERCENT HAVING 



Milk to 
drink 



At least 
1 pint 
of milk 
(esti- 
mated) 



Some 

fresh 

milk or 

cream 1 



Milk 
sufficient 

for 
fair diet 



No milk 
cream, 

or 
butter 



All children: 

Total 


1429 


54.0 


38.6 


79.9 


73.1 


4.7 


Greene 

Johnson 

Nodaway 

Harrison 

Livingston 


221 
312 
149 
115 
350 
282 


53.8 
48.4 
62.4 
42.6 
56.5 
56.8 


38.0 
31.2 
51.4 
21.9 
39.8 
45.7 


83.3 
73.4 
94.6 
73.1 
88.0 
69.2 


75.5 
66.7 
85.3 
67.0 
79.2 
66.7 


5.4 
3.2 
0.7 
5.2 
2.6 
10.3 


Rural children: 

Total 


1037 


56.6 


42.2 


81.6 


75.0 


4.7 


Greene 

Johnson 


199 
228 
149 


53.3 
54.0 
62.4 


36.7 
37.8 
51.4 
No recor 
43.6 
44.2 


83.0 
75.9 
94.6 
ds secure 
92.9 
68.2 


74.4 

69.4 

85.3 

d 


5.5 
2.6 

0.7 


Livingston 

Mississippi 


212 
249 


60.3 
55.0 


85.4 
65.5 


0.9 
11.7 


Town Children: 

Total 


392 


46.7 


29.1 


75.3 


68.4 


4.6 


Greene* 

Johnson 


22 

84 


59.1 
33.3 


50.0 
13.6 
None inc 
21.9 
34.1 
57.5 


86.4 
66.6 

luded in 
. 73.1 
80.4 
75.8 


86.4 

60.7 

survey . . 


4.5 
4.8 


Harrison 

Mississippi* 


115 

138 

33 


42.6 
50.7 
69.7 


67.0 
69.5 

75.8 


5.2 
5.1 



*Too few for reliable percentages, 
including soup or cocoa made of milk. 



43 



Diet Summary IV. 

DEFECTS OF EXCESS 

Percent of children under 16 years of age, showing specified errors of diet. 



County 



T-t If} 

C u 

o 



cd 



Eh 



Eating 

Meat 



■43 S 



Eating biscuit 



H 



W 



All children: 
Total... 



Greene. . . . 
Johnson. . . 
Nodaway. . 
Harrison. . . 
Livingston . 
Mississippi. 



Rural children: 
Total 



Greene. . . . 
Johnson. . . 
Nodaway. . 
Harrison . . . 
Livingston. 
Mississippi 



Town children: 
Total 



Greene*. . . 
Johnson. . . 
Nodaway. . 
Harrison . . . 
Livingston . 
Mississippi' 



1401 



24.2 



53.0 



22.4 



50.0 



217 
298 
147 
112 
346 
281 



30.3 
20.2 
18.1 
16.4 
21.2 
34.0 



40.7 
58.9 
65.3 
56.3 
40.8 
63.4 



16.7 
29.6 
30.6 
12.5 
11.9 
31.7 



75.2 
56.7 
17.0 
9.8 
19.4 
95.0 



1019 



24.6 



55.3 



24.6 



57.3 



196 
217 

147 



27.9 
20.2 
18.1 



210 
249 



20.8 
33.4 



41.6 
64.8 
65.3 
No re 
43.3 
62.2 



18.5 
31.0 
30.6 
cords 
13.3 
29.7 



77.1 
60.8 
17.0 
secur 
18.5 
95.6 



382 



23.1 



46.6 



16.5 



30.6 



48.1 
20.2 



112 

136 

32 



16.4 
21.7 
39.4 



33.3 
43.2 
None 
56.3 
36.8 
71.8 



25.9 
inclu 
12.5 
9.6 
46.8 



57.2 
45.6 
ded 
9.8 
20.6 
90.6 



20.1 



19.3 



24.4 

10 

2.0 



69.0 



24.5 



25.5 

11.5 

2.0 

ed. 



69.1 



8.4 



14.3 
8.6 

n sur 



68.8 



19.1 
9 

2.7 

0.9 

0.3 

62.0 



21.8 



19.1 

11.1 

2.7 



0.5 
62.3 



7.6 



19.1 

6.2 

vey . . 

0.9 



59.5 



5.3 



4.1 
5.7 
8 1 
13.4 
3.2 
3.6 



4.0 



3.1 
3.2 
8.1 



3.8 
3.6 



8.3 



1.4 
12.4 



13.4 
2.2 
3.1 



25.9 



41.9 
27.9 
23.1 
25.7 
19.9 
20.3 



27.0 



41.8 
27.6 
23.1 



19.0 
22.9 



23.0 



42.8 
25.9 



25.7 
21.3 



"Too few for reliable percentages. 



44 



Diet Summary V. 



DEFICIENCIES IN DIET 
(Other than Milk) 



Percent of children under 16 years of age, eating specified articles of food. 



County 



Total 
number 

of 
reports 



Cereal 



Eggs 



Fruit 
other 
than 
pre- 
served 



Vege- 
table 1 



Eating 

neither 

fruit 



vege- 
table 



All children: 

Total 


1401 


47.3 


34.7 


62.1 


42.3 


21.1 


Greene 

Johnson 

Nodaway 

Harrison 

Livingston 

Mississippi 


217 
298 
147 
112 
346 
281 


52.0 
37.3 
47.6 
53.5 
59.8 
36.3 


50.2 
12.8 
10.9 
19.7 
63.8 
28.5 


60.8 
80.5 
83.6 
58.0 
66.2 
29.2 


54.8 
43.0 
34.7 
31.3 
25.7 
60.9 


15.2 
14.1 
11.6 
34.0 
26.0 
27.0 


Rural children: 

Total 


1019 


46.3 


36.9 


62.8 


43.8 


18.9 


Greene 

Johnson 

Nodaway 


196 

217 
147 


53.5 

34.1 
47.6 


52.0 

17.5 
10.9 
No recor 
68.1 
30.9 


59.2 
84.3 
83.6 

ds secure 
70.0 
28.5 


52.5 

48.0 

34.7 

d 


15.8 

9.2 

11.6 


Livingston.' 

Mississippi 


210 
249 


61.0 
37.0 


16.7 
61.4 


26.7 
27.3 


Town children: 

Total 


382 


50.2 


28.8 


60.5 


38.5 


27.2 


Greene* 

Johnson 


21 
81 


28.6 
45.7 


33.3 

None inc 

19.7 

57.4 

9.4 


76.2 
70.4 
luded in 
58.0 
60.3 
34.4 


76.2 
29.6 

survey . . 


9.5 

27.2 


Harrison 

Livingston 

Mississippi* 


112 

136 

32 


53.5 
58.1 
31.2 


31.3 
39.7 
56.3 


34.0 
25.0 
25.0 



*Too few for reliable percentages. 

1 Other than white potatoes or dried legumes. 



45 



Diet Summary VI. 

IRREGULAR EATING 

Percent of children under 16 years of age, eating as specified. 



County 



After 
school 



At 
recess 



At other 
times 



Frequently 

and 
irregularly 



Omitting 
a meal 



All children: 

Total 


70.3 


39.3 


17.8 


6.0 


4.7 






Greene* 

Johnson* 

Nodaway 

Harrison 

Livingston 

Mississippi 


73.2 
65.8 
68.0 
49.1 
76.4 
76.2 


.... No rec 
.... No rec 

66.6 
6.5 

25.2 

56.0 


ord 

ord 

20.4 
6.2 

11.2 

29.2 


6.0 
5.6 
0.7 
2.7 
7.2 
8.9 


3.7 
3.0 
2.0 
6.2 
6.9 
5.3 


Rural children: 

Total 


73.4 


52.4 


21.6 


6.7 


3.9 


Greene* 

Johnson* 

Nodaway 


73.2 
65.9 
68.0 


.... No rec 
.... No rec 

66.6 
No record 

36.8 

56.5 


ord 

20.4 


5.1 
6.0 

0.7 


2.6 
3.7 
2.0 


Livingston 

Mississippi 


79.6 
77.9 


11.9 
30.6 


9.0 
10.0 


6.2 
4.4 


Town children: 

Total 


62.3 


12.8 


9.3 


4.2 


6.8 






Greene* 


No 


records se 

.... No rec 

None inclu 

6.5 

8.8 

51.6 


cured 

ord 

ded in surv 
6.2 

10.3 

18.8 


14.3** 
4.8 


14.3** 


Johnson* 


65.4 


1.2 


Harrison 

Livingston 

Mississippi**.. . . 


49.1 
71.4 
62.5 


2.7 
4.4 


6.2 

8.1 

12 1 







*Records not in all cases specific as to when extra meal was taken, but pre- 
sumably after school. 

**Too few for reliable percentages. 



46 



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020 948 945 4 



